General medicine case discussion

 This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending     clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.   

K. Tejarshini (Intern) 

A 80 Year old female presented with complaint of, 

Fever:1 Week

Patient was apparently asymptomatic 1 week back then she complained of fever of high grade(104F), Intermittent, not associated with chills and rigors.Fever get relieved on medication.Associated with head ache. 

There is no history of vomitings,oose stools, pain abdomen, cold, cough, Burning micturition. 

Not a known case of DM, HTN, Asthma, Epilepsy, CAD, CVD. 

Personal History:

Appetite:Normal

Diet:Mixed

Bowel and bladder habits:Regular

No addictions

General Examination:

Conscious, Coherent, Co-operative

No Icterus,Cyanosis,Clubbing,lymphadenopathy,

Pedal edema. 

Pallor present




Raised  JVP

Vitals:

Temp- 104.5F
Bp- 80/50mm hg
PR- 150bpm
RR-16cpm
Spo2- 99% on RA
GRBS-123 mg/dl

Systemic Examination:
Cardiovascular System : S1, S2 heard, no murmurs

Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.RT LL Coarse crepts+

Central Nervous System : patient is conscious coherent and cooperative. Higher mental functions intact 

Per abdomen : soft, non tender. No organomegaly.

INVESTIGATIONS :- 

HEMOGRAM 

HB 11.4GM/DL 
TLC 9,200
N/L/E/M/B. 89/10/#00/01/00
PCV #34.8
MCV 86.4
MCH 28.3
MCHC 32.8
RDW-CV 12.6
RDW-SD 40.6
RBC. 4.03
PLT. 100000

CUE :- 
ALBUMIN 
BILE SALTS AND PIGMENTS   NIL
PUS CELLS   NIL 

LFT :- 
TB  1.23MG/DL
DB 0.39MG/DL
SGOT 88IU/L 
SGPT 51IU/L 
ALP.   159IU/L
TP   4.9gm/dl 
albumin. 2.5gm/dl 
A/G RATIO. 1.06

RBS:97 mg/dl
APTT:36sec
BT:2min
CT:5min
BHT:O+ve
PT:18sec
INR:1.33

Serology:
Hbs Ag:-ve
Anti HCV:NR
HIV:NR

RFT:
Serum urea:5.8
Serum creatinine:1.2
Electrolytes:
Sodium:134
Potassium:3.6
Chloride:103
Ionized calcium:0.91


USG Abdomen:




CHEST X RAY:


ECG:






PROVISIONAL DIAGNOSIS:

DISTRIBUTIVE SHOCK SECONDARY TO SEPSIS
VIRAL PYREXIA WITH THROMBOCYTOPENIA. 

Treatment:
IVF-NS, RL@100ml/hr
Inj. NEOMOL1gm IV SOS if temp>101f
Tab. DOLO 650mg PO/TID
ORS Sachets 2 in 1lit of water, 200ml every hour

Soap notes:

5/01/2023
AMC
Bed no:1
Unit-3
. Nikitha (SR)
Dr. Vamshi (Pgy3)
Dr. Nishitha (Pgy2)
Dr. Govardhini (Pgy1)
S:
2 Spikes of Fever-Last night-104F-Neomol inj, 100.1F
Stools passed.
C/O Generalized body pains
O:
Temp- Afebrile 
Bp-110/60mm hg
Pr- 94bpm
Rr-16cpm
Spo2- 99% on RA
GRBS:110mg/dl
I/O charting:2600/200ml
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.RT LL Coarse crepts+
Central Nervous System : patient is conscious coherent and cooperative. Higher mental functions intact 
Per abdomen : soft, non tender. No organomegaly.
A:
DISTRIBUTIVE SHOCK SECONDARY TO SEPSIS
VIRAL PYREXIA WITH THROMBOCYTOPENIA. 
Treatment:
IVF-NS, RL@100ml/hr
Inj. NEOMOL1gm IV SOS if temp>101f
Tab. DOLO 650mg PO/TID
ORS Sachets 2 in 1lit of water, 200ml every hour.

06/01/2023
AMC
Bed no:1
Unit-3
Dr. . Nikitha (SR)
Dr. Vamshi (Pgy3)
Dr. Nishitha (Pgy2)
Dr. Govardhini (Pgy1)
S:
2 Spikes of Fever-Last night-102F-Neomol inj, morning 7am -104F-Inj. Neomol
Stools passed.
O:
Temp- Afebrile 
Bp-90/50mm hg
Pr- 126bpm
Rr-16cpm
Spo2- 99% on RA
GRBS:70mg/dl
I/O charting:2600/500ml
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.B/L crepts+ in infrascspular area
Central Nervous System : patient is conscious coherent and cooperative. Higher mental functions intact 
Per abdomen : soft, non tender. No organomegaly.
A:
DISTRIBUTIVE SHOCK SECONDARY TO SEPSIS
VIRAL PYREXIA WITH THROMBOCYTOPENIA. 
P:
IVF-NS, RL@100ml/hr
Inj. NEOMOL1gm IV SOS if temp> or =101f
Tab. DOLO 650mg PO/TID
ORS Sachets 2 in 1lit of water, 200ml every hour.

7/01/23

ICU
Bed no:4
Unit-3
Dr. . Nikitha (SR)
Dr. Vamshi (Pgy3)
Dr. Nishitha (Pgy2)
Dr. Govardhini (Pgy1)
S:
No fever spikes
Stools passed.
O:
Temp- Afebrile 
Bp-100/80mm hg
PR- 104bpm
RR-16cpm
Spo2- 99% on RA
GRBS:120mg/dl
I/O charting:1950/2200ml
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.B/L crepts+ in suprascapular area, mammary, infra axillary areas.
Central Nervous System : patient is conscious coherent and cooperative. Higher mental functions intact 
Per abdomen : soft, non tender. No organomegaly.
A:
DISTRIBUTIVE SHOCK SECONDARY TO SEPSIS-VIRAL
PYREXIA WITH THROMBOCYTOPENIA(Resolving)
P:
IVF-NS, RL@100ml/hr with optineuron
Inj. NEOMOL1gm IV SOS if temp> or =101f
Tab. DOLO 650mg po/TID
ORS Sachets 2 in 1lit of water, 200ml every hour.

08/01/23
ICU
Bed no:4
Unit-3
Dr. . Nikitha (SR)
Dr. Vamshi (Pgy3)
Dr. Nishitha (Pgy2)
Dr. Govardhini (Pgy1)
S:
Fever spike at 7Am today
Stools passed.
O:
Temp- Afebrile 
Bp-90/80mm hg
PR- 110bpm
RR-16cpm
Spo2- 99% on RA
GRBS:120mg/dl
I/O charting:1950/2200ml
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.B/L crepts+ in suprascapular area, mammary, infra axillary areas.
Central Nervous System : patient is conscious coherent and cooperative. Higher mental functions intact 
Per abdomen : soft, non tender. No organomegaly.
A:
DISTRIBUTIVE SHOCK SECONDARY TO SEPSIS-?VIRAL
PYREXIA WITH THROMBOCYTOPENIA(Resolving) with type1 Respiratory failure secondary to? Interstitial pneumonia
P:
IVF-NS, RL@100ml/hr with optineuron
Inj. NEOMOL1gm IV SOS if temp> or =101f
Tab. DOLO 650mg po/TID
ORS Sachets 2 in 1lit of water, 200ml every hour. 

10/01/23
ICU
Bed no:4
Unit-3
Dr. . Nikitha (SR)
Dr. Vamshi (Pgy3)
Dr. Nishitha (Pgy2)
Dr. Govardhini (Pgy1)
S:
Fever spike  @ 8:00AM
O:
Temp- 101.4F
Bp-120/60mm hg
PR- 110bpm
RR-16cpm
GRBS:121mg/dl
I/O charting:3050/2350 ml
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.B/L crepts+ in suprascapular area,Supra mammary, infra axillary areas.
Central Nervous System : patient is conscious coherent and cooperative. Higher mental functions intact 
Per abdomen : soft, non tender. No organomegaly.
A:
DISTRIBUTIVE SHOCK (Resolved)SECONDARY TO SEPSIS-?VIRAL
WITH THROMBOCYTOPENIA(Resolved) with type1 Respiratory failure secondary to? Interstitial pneumonia(viral)
P:
IVF-NS, RL@100ml/hr
Tab. DOLO 650mg po/QID
ORS Sachets 2 in 1lit of water, 200ml every hour.
Neb with IPRAVENT- 8 thHOURLY, BUDECORT-12 thHOURLY




 








 

















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