A 40 year old woman with fever, vomiting, diarrhoea and SOB

General Medicine Case Discussion
June 07, 2023
General medicine case discussion

E LOG MEDICINE CASE

07/06/2023

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.


Name : U.Sri Vidya 

Roll no : 121

2020 Batch

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 comeup with Diagnosis and Treatment plan.

CASE DISCUSSION

Date of admission: 06-06-2023
A 40 year old female patient came to medical OPD with

Cheif complaints
SOB since 4 days
Fever since 4 days
Vomiting since 3 days
Pain and tightness of abdomen since 3 days
Diarrhoea since 3 days
Oliguria since 3 days


History of presenting illness
Patient was apparently asymptomatic 2 months back, then she developed SOB
High grade fever, no chills and rigor, intermittent type, and relieved temporarily on medication
Vomiting 3-4 episodes,non bilious,non projectile, containing food particles.
Bloating of abdomen since 3 days
Diarrhoea since 3 days ,Watery and no smell
Oliguria since 3 days, no pain during micturion.

Past History

K/c/o thyroid since 10 years
No history of DM, HTN, Epilepsy,CAD, asthma

Drug history

Thyroxine 100mg

Surgical history

C section
Tubectomy

Family history 
No significant family history

Personal history
Married
Mixed diet
Appetite: lost
Sleep: normal
Addictions: toddy (occasionally)
No allergies 
Bowel movement:  increased

Physical examination
  General Examination
   Conscious, coherent, cooperative 
   Oriented time , place and person
   Moderately built
   No pallor
   No icterus
   No cyanosis
   No clubbing of fingers 
   No pedal edema
   No lymphadenopathy

Vitals
  Temperature: febrile
  Pulse:106
 
 Systemic examination

Abdomen
Shape-obese
Tenderness -present
No palpable mass
CNS
Speech-normal
No neck stiffness 

Investigations
  




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