case discussion on 42 year old male with fever

General Medicine Case Discussion
June 09, 2023
General medicine case discussion

E LOG MEDICINE CASE

09/06/2023

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:07-06-23


Cheif complaints:
Fever since 4 days
Vomiting 


History of presenting illness:The patient was apparently asymptomatic 4 days back when he developed fever which was incidious in onset, gradually progressive,  high grade , associated with chills and rigor and relived on medication.

Decreased urine output since 4 days.No history urgency or hesitancy in urinating.

The 1 episode of vomiting, was around 1 pm the 4 days back, non bilious, non projectile, non blood stained with food as content.

No H/o headache, neck stiffness, loose stools, abdominal pain



past history:
 In Febuary 2023, patient developed abdominal tightness and chest discomfort and was hospitalized outside. Endoscopy was done there and he was diagnosed to have Antral gastritis. 
1 month back patient presented with complaints of abdominal distension, pedal edema, lower back ache. He was hospitalized and found to have diabetes mellitus type 2 along with Chronic Kidney Disease. An MRI of lumbo sacral spine showed mild canal stenosis at L4-L5 and moderate canal stenosis at L3-L4 (early lumbar
He is a k/c/o Hypertension since 4 years, on Tab. STAMLO BETA 0.5 mg PO/OD.

For his Type 2 DM, for 1 month, he has been taking Inj. HAI 8 U in the morning and 4 U in the evening s/c.

Not a k/c/o TB, asthma, epilepsy, CAD

No major surgeries, no blood transfusions.

Personal history

Married

Appetite normal

Mixed diet

Bowels regular

Micturition : abnormal( pain)

No allergies

Addictions: tobacco snuff

Family history

So significant family history 


General examination 

Patient is conscious, coherent and cooperative.

Pallor- Present


Icterus- absent

Cyanosis- absent

Clubbing- absent

Lymphadenopathy - absent

Edema- Absent 


Vitals

Temp: febrile 

PR: 90 bpm

RR: 20 cpm

BP: 110/80 mmHg

SpO2: 98%

Systemic examination

CVS

S1&S2 heard

Abdomen: scaphoid, soft, no tenderness

Respiratory system:Central trachea

CNS: oriented to time place and person

Speech normal 



Investigations
















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