55yr old female complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools .
SHIVA KUMAR SRIRAM 152
A 55yr old female complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days.
October 27, 2022
CHIEF COMPLAINTS:
Pt complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days.
HOPI:
Patient was apparently asymptomatic 3 months back. Then she had multiple swellings in front of the left ear, for which she developed fever which was lowgrade, intermittent, no evening rise of temp, ass with decreased appetite since 1 month. She then had vomitings which was non bilious and non projectile, containing food particles. She had history of loose stools since 3 days, which is 4-5 episodes per day, watery in consistency.
Past history:
K/c/o Hypertension since 7 years.
7 yrs back she had c/o giddiness for which she went to hospital and was found to have HTN.
Personal history:
Diet- mixed
Appetite-decreased
Bowel and Bladder movements- regular
.
Addictions-
Allergies- none
General examination:
Patient is conscious, coherent and cooperative. Well oriented to time, place and person.
Moderately built and moderately nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
Vitals:
Temp- 98°F
BP-110/80MMHG
RR-18CPM
PR- 74BPM.
GRBS-92mg/dl on the day of admission.
Spo2 - 100%
Systemic Examination:
CVS: S1,S2 Heard
No Murmurs
RS: B/L Normal Vesicular Breath Sounds Heard.
CNS:NAD
P/A: On Inspection:
Shape - scaphoid
Umbilicus inverted
No scars and sinuses present.
No visible pulsatios , no engorged veins
On palpation:
No rebound tenderness, no gaurding, no rigidity
No organonegaly
On percussion:
No fluid thrill
No shifting dullness
On Auscultation:
Bowel sounds heart
Systemic Examination:
CVS: S1,S2 Heard
No Murmurs
RS: B/L Normal Vesicular Breath Sounds Heard.
Treatment:
1) IV FLUIDS(2units NS, 1unit RL) @100ml/hr.
2) INJ. NEOMOL 1GM/IV/SOS(IF temp>101°F).
3) INJ. METROGYL 100Ml/IV/TID.
4)INJ PAN 40MG/IV/BEFORE BF.
5) INJ.ZOFER 4MG/IV/OD.
6) CAP. RETODRIL 100MG/PO/TID.
7) TAB. SPORLAC-DS ,2TAB/PO/TID.
8) ORS SACHETS IN 1LITRE OF WATER, 200ML TO BE TAKEN AFTER PASSAGE OF EACH STOOL.
9)T.DOLO 650MG/PO/BD.
10) MONITOR VITALS.
11) INFORM SOS.
DIAGNOSIS:
ACUTE VIRAL GASTROENTERITIS.
K/C/O HTN SINCE 7YRS.
HIV POSITIVE (DENOVO DETECTED).
Popular posts from this blog
A 45 yr old male c/o fever since 5 days.Abdominal pain , loose stools and vomitings since yesterday.
October 15, 2022
Image
CHIEF COMPLAINTS : A 45 yr old male c/o fever since 5 days, abdominal pain , loose stools and vomitings since yesterday. HOPI : patient was apparently asymptomatic 5 days ago and then developed fever, which is low grade, not associated with chills and rigors and relieved on medication. He complains of diffuse pain abdomen since 11th October morning. He had 3-4 episodes of vomiting on the same day evening, food particles as content and non- bilious in nature .He had loose stools since evening the same day, which is of 5 -6 episodes and so he went to local hospital. He developed weakness of both upper and lower limbs and found to be having low potassium, correction was done and the weakness got improved. He now came with c/o abdominal pain , vomiting and loose stools. PAST HISTORY Not a k/c/o DM, Hypertension, Asthma, epilepsy, CAD, CKD. He went for a General checkup 6yrs ago, where he was diagnosed as HIV posi tive. He was on ART . He met with an accident 3yrs ago and got Righ
READ MORE
55 yrs old male patient with came with cheif complaints of abdominal pain since 5 days and chest pain since 2 days.
January 10, 2022
Image
Student- G.Pranay kumar Batch- 2017 This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input This E blog also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. CHEIF COMPLAINTS: Patient came with cheif complaints of abdominal pain since 5 days and chest pain since 3 days. HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic
READ MORE
SHORT CASE - Final MBBS Practical Examination
June 08, 2022
Image
A 47 year old female with fever and joint pains June 07, 2022 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. G. Pranay Kumar Roll no 32 Hall ticket no : 1701006045 Chief Complaints:- A 47 year old female tailor by occupation resident of nalgonda came to the OPD with the chief complaints of: Fever since 3 months Facial rash since 10 days HISTORY OF PRESENT ILLNESS:- Patient was apparently asymptomatic 10 years ago then she developed joint pains first in the both knees and ankles followed by both the hands.There was swelling as
READ MORE
Powered by Blogger
Report Abuse
Comments
Post a Comment