A 60years Old Patient With Dengue Fever

THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT 
CHEIF COMPLAINTS:-
C/O back pain since 20 days 
C/O fever since 10 days 
C/O burning Micturition since 10 days 
HISTORY OF PRESENT ILLNESS :-
Patient admitted in hospital on 24-3-2022 at 5:40pm.
Patient was apparently asymptomatic 20 days ago. Then developed back pain- dragging type, aggravated on sitting, relieved with medication and rest. 
C/O fever since 10 days- high grade, continous, 
relieved with medication (PCM - TID).
H/O burning micturition since 10 days .
H/O vomiting 2-3 episodes in 10 days ( non billions, non projectile).
HISTORY OF PAST ILLNESS :-
H/O headache- generalized since 2 days 
No H/O blurring vision. 
No H/O cough, cold, loose stools,joint pains.
N/K/C/O  DM, Hypertension,TB,epilepsy,CVA,BA, Thyroid disorders,CAD,Asthma, Antibiotics, Hormones, chemo/radiation, blood transfusion. 
PERSONAL HISTORY:-
Married
Diet- Non veg
Bowels- regular 
Micturition- burning micturition since 10 days 
Known allergies- no
FAMILY HISTORY:-
no significant family history 
GENERAL EXAMINATION:-
no pallor, cyanosis, icterus, lymphadenopathy, clubbing of fingers or toes, Oedema of feet, malnutrition, dehydration. 
VITALS:-
Temp- 36.1c
Pr- 86/ min
Rr-18/ min
Bp-110/70 mm /Hg
Spo2- 98%
SYSTEMIC EXAMINATION:-
a)CVS - S1 S2 Positive 
b)Respiratory system-NVBS Positive 
                                  -BAE Positive 
c)Abdomen- soft, non tender
d)CNS
    Level of consciousness- alert
    Speech- normal 
     Signs of meningeal irritation like neck           
      Stiffness, kerning 's sign- no
     Cranial system, motor system, sensory 
     system- normal.
     no cerebral signs
INVESTIGATIONS:-







Comments

Post a Comment

Popular posts from this blog

A 55 YEAR OLD MALE PATIENT WITH SUPERFICIAL BURNS AND ACUTE PANCREATITIS

Image
January 18,2023 This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.  A 55 year old male patient shepherd by occupation  came to the opd with the chief complaints of burns over the face due to oil spillage and pain in the abdomen since two days . Date of admission :14/01/2023 HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic  3years back ,then he noticed fever associated with body aches for which he went to a hospital where he was diagnosed with diabetes mellitus and was on oral hypoglycemic agents since 3years.  Then 3 days back, he underwent trauma ( burns -oil spillage as he had stepped on fire camp)under the effect of alcohol (90m
Read more

A 10Months Male Child With Bronchiolitis with Grade 3 PEM

THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT  CHEIF COMPLAINTS:- C/O fever since 1week C/O Cold since 1week  C/O cough since 1week  HISTORY OF PRESENT ILLNESS:- Baby was apparently asymptomatic 1week back When he developed  1) Fever- sudden onset                - moderate grade                - interfebrile period               - not associated with chills/ rigors                - subsided on taking medication                 - associated with excessive cry or                             irritability   2) cold- associated with rapid breathing               - nasal block Positive               - running nose Positive               - more during night  3)
Read more

A 45Years old male patient with Decreased sensation of Right foot.

Image
THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT  CHEIF COMPLAINTS:- Patient complaint of decreased sensation of Right foot. Blackish discolouration of right toe since 2 weeks Bedsore on the back since 1month. H/O previous amputation of left leg above knee . HISTORY OF PRESENT ILLNESS :- Patient was apparently asymptomatic 1month back,then he developed Ulcer over the lower back of body  which is the dependent portion while he was lying in supine position . It is gradual in onset and progressive in nature. No H/O of discharge.  No  H/O of fever.  L/E of ulcer A 4×3cm ulcer was present over the coccygeal region.  Margins are inflamed. Edges are slopy Floor is
Read more