31 yr old female with fever since 5 months

This 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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 



A 31 year female came with chief complaints of fever since 5 months

Fever is high grade associated with chills and rigor 
It is intermittent in nature
No diurnal variation
It is associated with vomiting , food as content , no bilious , non projectile , no blood stained  
H/o loss of appetite & weight loss +
H/o burning sensation over the tongue and buccal mucosa since 3-4 months, insidious in onset, gradually progressive, aggravated when patient consumes spicy food and no relieving factors

No h/o cough, cold
No h/o chest pain , sob, orthopnea, pnd
No h/o loose stools, constipation
No h/o burning micturition, increased/decreased urine output.
PAST HISTORY

Not a known case of hypertension, DM, asthma, tuberculosis, epilepsy, CVA, CAD.

GENERAL EXAMINATION

Patient is conscious coherent cooperative moderately built and nourished 
Mild Pallor ,No Icterus Clubbing Cyanosis Edema 
Vitals : 
PR : 76 bpm
BP : 110/70 mmHg 
RR : 20 CPM
Temperature : 101f
Spo2 : 98 %
GRBS : 92mg /dl

SYSTEMIC EXAMINATION

CVS : S1 and S2 heart sounds heard
CNS: NO focal neurological deficits 

RR: BAE Present, normal vesicular breath sounds heard,no adventitious sounds

shape of the chest: normal

trachea appears to be central

Per abdomen: soft, non tender

Chest x ray
INVESTIGATIONS 
TREATMENT 

1. IV FLUIDS NS RL @50ML/HR
2. INJ . PCM 1GM IV /SOS IF TEMP >101F
3. TAB. PCM 650 MG PO TID 
4. INJ ZOFER 4MG IV/ TID 
5. ZYTEE GEL FOR L/A BD 
6. 2% BETADINE GARGLES 5ML DILUTED IN 1 GLASS OF WATER 3 TIMES A DAY 
7. TAB . MVT PO OD

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