70 year old female came to opd with chief complaints of fever since 15 days

This is online E log book 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 series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on 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.
I have prepared this blog under the guidance of
Dr. Sai Charan Kulkarni, Dr. Deepika 

A 70 year old female came with chief complaints of

C/o fever since 15 days 

C/o vomitings since 10 days.

C/o Body pains since 10 days

C/o dryness of tongue since 4 days


HISTORY:


Patient was apparently asymplomatic 5-6 years back, then she developed burning sensation of feet  and lower limbs for which she was investigated, and Diagnosed as Diabetic neuropathy and was given Symptomatic treatment and stopped using those medications.



HISTORY OF PRESENT ILLNESS;



FEVER -continous, intermittent, decreased wiith medication, no durinal variation

Not A/W cold, cough, buming mictuation, loose stools

Vomtings -  occationally ( on and off )

• Occurs only if the consumes food)

4-5 times a day

and non bilious, non projectile, food particles as content

Dryness of tongue - A/W pain @ inner buccal mucosa, swelling @,



PAST HISTORY:


She is a known case of
- Diabetes since 15 years(metformin and glimi 1;  Presently-glimi2)

 -Hypertension since 3 years(losartan and hydrochlorthiazide)

 -Underwent right eye operation 1 year back
 -Piles since 10 months 



PERSONAL HISTORY;


She wakes up at around 6:00am goes  for 1 hour walk and 
-has milk or Java and
-in afternoon around 12 pm she eats rice with some vegetable curry (she takes only veg diet)
-and around 8 pm She eats Gatka 

-Appetite decreased 

-Sleeps only 3 to 4 hours

-Bladder - normal

-Bowel    -She takes syrup every night then next day    morning she passes faeces. If she tries hard to pass   faeces without having syrup ; then she bleeds per  rectum.

-No addictions 





GENERAL PHYSICAL EXAMINATION:

Patient is Conscious ;Coherent and Cooperative  
And Well oriented to Time ;Place and Person

  Pallor                       - Present 

  Icterus                     - Absent

  Cyanosis                  -Absent

  Clubbing                   -Absent

 Generalised Lymphadenopathy     - Absent

  Bilateral Pedal Edema     - Absent


RASH



VITALS:

Temperature - 98.3F

Pulse rate :

Supine- 68bpm

Standing - 72bpm

BP : 

Supine - 130/70mm hg

Standing - 110/60mm hg 

RR - 23cpm

Spo2-98%

GRBS - 96mg/dl

FEVER CHART


PLATELET COUNT:




GRBS :

P

 INVESTIGATIONS:







PROVISIONAL DIAGNOSIS:

Viral Pyrexia with Thrombocytopenia
 
TREATMENT:

12/10/22


O:
Patient is conscious coherent and cooperative 
Vitals : 
Temperature - 97.6 F
Pulse rate- 65
RR - 18
Bp - 120/70
Spo2-95
CVS - S1S2+
RS - BAE+
P/A - Soft, Non tender
CNS- NFND

A:
FEVER with THROMBOCYTOPENIA
 ? CERVICAL SPONDYLOLIS.

P:
 
1. IVF - NS/RL@150ml/hr
2. TAB NEOMOL Ig IN (SOS
3. Tab -DoLo 650mg/po/sos
   4. Tab - GLIMIPERIDE long/po/od/ before food 
   5 .Tab - METFORMLIN 800mg / Po/Od
   6. GRBS  monitoring 8th hourly 
   7 .Temp Charting ith houry 
   8. WIF Bleeding manifestation postural drop

13/10/22


Amc bed - 3
O:
Patient is conscious coherent and cooperative 
Vitals : 
Temperature - 98.3F
Pulse rate :
Supine- 60 bpm
Standing - 64bpm
BP : 
Supine - 120/70mm hg
Standing - 110/60mm hg 
RR - 20
Spo2-98
CVS - S1S2+
RS - BAE+
P/A - Soft, Non tender
CNS- NFND

A:
FEVER with THROMBOCYTOPENIA
 ? CERVICAL SPONDYLOLIS.

P:
 
1. IVF - NS/RL@150ml/hr
2. TAB NEOMOL Ig IN (SOS
3. Tab -DoLo 650mg/po/sos
   4. Tab - GLIMIPERIDE long/po/od/ before food 
   5 .Tab - METFORMLIN 800mg / Po/Od
   6. GRBS  monitoring 6th hourly 
   7 .Temp Charting 4th houry 
 8. WIF Bleeding manifestation postural drop
  9. ULTRACET 1/2 tab/OD/QID
  10. PREGABALIN 75mg / HS

14/10/22


Amc bed - 3 
O: Patient is conscious coherent and cooperative  

Vitals :  
Temperature - 98.3F 
Pulse rate :
 Supine- 56bpm 
Standing - 66bpm 
BP :  
Supine - 130/80mm hg 
Standing - 100/70mm hg  
RR - 23cpm 
Spo2-98%
 CVS - S1S2+
 RS - BAE+
 P/A - Soft, Non tender 
CNS- HMFA  

A: FEVER with THROMBOCYTOPENIA  ? CERVICAL SPONDYLOLIS  ? DIABETIC NEUROPATHY 


  P:   1. IVF - NS/RL@150ml/hr 
2. TAB NEOMOL Ig IN (SOS 
3. Tab -DoLo 650mg/po/sos    
4. Tab - GLIMIPERIDE 1 mg/po/od/ before food   
  5 .Tab - METFORMLIN 800mg / Po/Od after food    6. GRBS  monitoring 6th hourly   
  7 .Temp Charting 4th houry 
  8. WIF Bleeding manifestation postural drop 
  9. ULTRACET 1/2 tab/OD/QID   
10. PREGABALIN 75mg / HS  
11.INJ.ZOFER 4mg/IV/BD 
  12.INJ.PAN 40mg/IV/OD

15/10/22


O:
Patient is conscious coherent and cooperative 
Vitals : 
Temperature - 98.3F
Pulse rate :
Supine- 68bpm
Standing - 72bpm
BP : 
Supine - 130/70mm hg
Standing - 110/60mm hg 
RR - 23cpm
Spo2-98%
GRBS - 96mg/dl
CVS - S1S2+
RS - BAE+
P/A - Soft, Non tender
CNS- HMFA

A:
FEVER with THROMBOCYTOPENIA
 ? CERVICAL SPONDYLOLIS  ? DIABETIC NEUROPATHY 

P:
 
1. IVF - NS/RL -3
2. TAB NEOMOL Ig IN (SOS
3. Tab -DoLo 650mg/po/sos
   4. Tab - GLIMIPERIDE 1 mg/po/od/ before food 
   5 .Tab - METFORMLIN 500mg / Po/Od after food
   6. GRBS  monitoring 6th hourly 
   7 .Temp Charting 4th houry 
 8. WIF Bleeding manifestation postural drop
  9. ULTRACET 1/2 tab/OD/QID
  10. PREGABALIN 75mg / HS
11.INJ PAN 40mg/IV/BD
12. ZOFER 4g/IV/BD

16/10/22

O:
Patient is conscious coherent and cooperative 
Vitals : 
Temperature - 98.6 F
Pulse rate :
Supine- 74bpm
Standing - 70bpm
BP : 
Supine - 120/70mm hg
Standing - 110/60mm hg 
RR - 22cpm
Spo2-98%
GRBS - 100mg/dl
CVS - S1S2+
RS - BAE+
P/A - Soft, Non tender
CNS- HMFA

A:

FEVER with THROMBOCYTOPENIA
 ? CERVICAL SPONDYLOLIS  ? DIABETIC NEUROPATHY 

P:
 
1. IVF - NS/RL -3
2. TAB NEOMOL Ig IN (SOS
3. Tab -DoLo 650mg/po/sos
   4. Tab - GLIMIPERIDE 1 mg/po/od/ before food 
   5 .Tab - METFORMLIN 500mg / Po/Od after food
   6. GRBS  monitoring 6th hourly 
   7 .Temp Charting 4th houry 
 8. WIF Bleeding manifestation postural drop
  9. ULTRACET 1/2 tab/OD/QID
  10. PREGABALIN 75mg / HS
11.INJ PAN 40mg/IV/BD
12. ZOFER 4g/IV/BD










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