A 38 year old male with fever ,headache and vomiting

2k 18 MBBS

 is an a 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 evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


I have 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.

Chief complaints -

38 year old male came to the Hospital with the chief Complaints of 
* Fever since 1 week
* Headache since 5 days
* Nausea and vomiting since 2 days 
History of present illness
Patient was apparently asymptomatic 5 years back then he was in stress as his brother had serious health issue. Following which he developed low grade fever and neck pains for which he was diagnosed as hypertensive

Since 1 week patient had fever which is of low grade  associated with chills and headache and neck pains.

No joint pains, burning Micturition No seizures 
Past History
Known case of Hypertension since 5 years on is using TAB. MET XL 50 mg
               TAB. TELMA 40 mg
* Not a known case of DM/CAD/ASTHMA/TB/ASTHMA/EPILEPSY
PERSONAL HISTORY

Diet - Mixed

Appetite - Normal

Sleep - adequate 

Bowel and Bladder Movements - Regular

 Addictions - None 
Family history- Not significant 

General Examination 

* Patient is conscious, coherent and co-operative and lying on the bed. 

* He is well oriented to time, place and person.

* He is moderately nourished.

Pallor - absent 
Icterus - absent 
Clubbing - absent 
Cyanosis - absent 
Lymphadenopathy - absent 
Edema-  absent

Vitals: 

Temperature - Afebrile

Pulse Rate - 121 BPM

Blood Pressure - 130/90 mm Hg

Respiratory Rate - 18 CPM

SPO2 - 99% at Room Air 

Random Blood Sugar - 130 mg/dl
Systemic Examination :

CARDIOVASCULAR SYSTEM - S1 and S2 present, No murmurs

RESPIRATORY SYSTEM - BAE +

PER ABDOMEN - Epigastric Tenderness present
Scaphoid shaped abdomen
No free fluid and palpable mass
No organomegaly

     
                      

Provisional Diagnosis

?? Sepsis with MODS
?? Leptospirosis

Treatment
1. IV FLUIDS RL @ 100 ml/hr
                       NS @ 100 ml/hr
2. INJ.PIPTAZ 2.25 gm IV/TID
3. INJ. ZOFER 4mg /IV/SOS
4. INJ. PAN 40 mg/PO/OD
5. TAB. PCM 650 mg /PO/QID
6. INJ. NEOMOL 1gm/IV/SOS 
7. TAB. DOXY 100mg PO/BD
8. INJ. OPTINEURON 1 amp in 100 ml NS IV/OD
9. INJ. TRAMADOL 1amp. in 100 ml NS IV/SOS
10. MONITOR VITALS AND INFORM SOS
11. TAB. MET XL 30 (50/12.5) PO/OD
27/08/2022

S: Fever spikes subsided

O:
Patient is conscious,coherent and cooperative 
BP - 130/100 mm Hg
PR - 96 bpm
RR- 18 cpm
Temp- 98.3 F 
spo2 - 98% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , EPIGASTRIC TENDERNESS PRESENT 
CNS-NAD

A : ?? SEPSIS WITH MODS SECONDARY TO BACTERIAL INFECTION
?? LEPTOSPIROSIS


P:
1. IV FLUIDS RL @ 100 ml/hr
                       NS @ 100 ml/hr
2. INJ.PIPTAZ 2.25 gm IV/TID
3. INJ. ZOFER 4mg /IV/SOS
4. INJ. PAN 40 mg/PO/OD
5. TAB. PCM 650 mg /PO/QID
6. INJ. NEOMOL 1gm/IV/SOS 
7. TAB. DOXY 100mg PO/BD
8. INJ. OPTINEURON 1 amp in 100 ml NS IV/OD
9. INJ. TRAMADOL 1amp. in 100 ml NS IV/SOS
10. Monitor vitals and inform SOS
11.TAB. MET - XL 30 (50/12.5) PO/OD




28/08/2022

S: Fever spikes subsided

O:
Patient is conscious,coherent and cooperative 
BP - 140/100 mm Hg
PR - 74 bpm
RR- 18 cpm
Temp- afebrile 
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , non tender
CNS-NAD

A : ?? SEPSIS WITH MODS SECONDARY TO BACTERIAL INFECTION
?? LEPTOSPIROSIS
P:
1. IV FLUIDS RL @ 100 ml/hr
                       NS @ 100 ml/hr
2. INJ.PIPTAZ 2.25 gm IV/TID
3. INJ. ZOFER 4mg /IV/SOS
4. INJ. PAN 40 mg/PO/OD
5. TAB. PCM 650 mg /PO/QID
6. INJ. NEOMOL 1gm/IV/SOS 
7. TAB. DOXY 100mg PO/BD
8. INJ. OPTINEURON 1 amp in 100 ml NS IV/OD
9. INJ. TRAMADOL 1amp. in 100 ml NS IV/SOS
10. MONITOR VITALS AND INFORM SOS
11. TAB. MET - XL 30 (50/12.5) PO/OD
12. INJ. LASIX 20 mg IV/SOS

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