GENERAL MEDICINE CASE DISCUSSION.

20th December, 2022

General medicine case discussion

E LOG MEDICINE CASE

20/12/2022

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: Kondakindi Vrithika Reddy

Roll no : 59

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:

Date of admission: 19th December, 2022. 

A 39 year old female house wife by occupation came to general medicine  OPD with chief complains of :fever, accommodated by headache and neck pain since five days. She is also having burps after taking food, after both solids and liquids. 

History of present illness:

Patient was apparently asymptomatic 5 days (15-12-2022) back then developed fever with headache on 16-12-2022 followed by dragging type of neck pain. She also noticed having burps after taking both solid and liquid diet. 

Personal History:

Appetite: Decreased appetite

Diet: Mixed

Bladder habits: regular

Bowel moments: reduced 

Addictions: Nil

Known Allergies: 

Drug History:

No known drug history

Past History: 

There is no history of DM,HTN,TB, EPILEPSY,ASTHMA, CAD, 

No history of blood transfusions.

No history of previous surgeries.

Family History:

Both her mother and father have hypertension. 

General Examination:

Conscious, coherent, and co-operative. 

Moderately built and nourished. 

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing of fingers: absent

Lymphadenopathy: absent

Pedal edema: absent

Vitals:

Temperature: 98.1 degrees Fahrenheit 

Pulse rate: 74 beats per min

Respiratory rate: 

BP: 100/70

SPO2: 100%

GRBS: 99mg% 

Systemic Examination:

A. CVS

1. S1 and S2 sounds heard
2. No audible mummers
3. No trills

B. Respiratory system:

1. Dyspnea: absent
2. Position of trachea: center
3. Normal vesicular breath sounds are heard
4. No adventitious sounds

C. Per-abdomen:

1. Scaphoid shaped abdomen
2. No visible swellings 
3. No visible scars and injuries
4. No tenderness
5. No palpable mass 
6. Bowel sounds: not hears

D. CNS:

1. Conscious 
2. Speech- normal
3. Signs of meningeal irritation - Nil
4. No neck stiffness
5. No kerming's sign
6. Cranial system - intact 
7. Motor system - intact 
8. Sensory system - intact 
9. Cerebeilar signs: Finger nose- in coordination, Knee heel - in coordination

Investigations:

1. Complete Blood Picture(CBP):

2. Complete Urine Examination: 

3. ECG: 

17-12-2022

19-12-2022

Provisional Diagnosis: Lymphopenia and Eosinopenia

Treatment: 

INJ PAN 40mG /IV /STAT

TAB: PCM 650mg/PO/QRD

TAB PAN 40 mg/PO/OD

TAB - MVT / PO /OD

INJ OPTINEURON 1AMP IN 50OMI NS/IV/STAT