40 year old female

This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Name: G Sai Manogna

Roll no 41

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 come up with a diagnosis and treatment plan.

Following is the view of my case :

CASE PRESENTATION:

A 40 year old female, farmer by occupation, resident of nalgonda came to the casualty with the chief complaints of

  • Fever since 10 days 
  • Cough since 10 days
  • Headache since 10 days
  • Neckpain since 10 days
Patient was apparently asymptomatic 10 days ago followed which she developed fever associated with chills and rigor which is insidious in onset and gradually progressive and is of continuous type, relieved on taking medication
Dry cough was developed 10 days ago which is insidious in onset and gradually progressive and is relieved on taking medication
C/o headache since 10 days
C/o neck pain since 10 days
No history of nausea, vomitings
No history of burning micturition, constipation
No h/o body pains
No h/o sob, palpitations
No h/o melena, bleeding per rectum

Past history
Not a k/c/o DM, HTN, asthma, TB, epilepsy
No past surgical history
No known allergies

Personal history
Diet- Mixed
Appetite- Decreased
Bowel and bladder movements- Regular
Sleep- Adequate
Addictions- None

Family history
No significant family history

Provisional diagnosis
Viral pyrexia

General examination
Done after obtaining consent, in the presence of attendant with adequate exposure
Patient is conscious, coherent, not cooperative but well oriented to time, place and person
Patient is well nourished and moderately built
 
No history of pallor, icterus, cyanosis, clubbing, edema and lymphadenopathy

Vitals
Temperature- Febrile- 101.2 F
Blood pressure- 110/70 mm of Hg
Pulse rate- 78 bpm
Respiratory rate- 18 cpm
SpO2- 98% at room air


Systemic Examination:

Cardiovascular System:
S1 and S2 sounds are heard
No abnormal murmers

Respiratory System:
Bilateral air entry present
Trachea is central
Normal vesicular breath sounds are heard
No adventitious sounds are heard

Abdominal Examination:
Shape of abdomen is distended
Soft and non tender
Bowel sounds are heard
No palpable mass
Hernial orifices are normal
No organomegaly

Central Nervous System:
No focal neurological deficits

Investigations
Hemogram

HB- 9.4
TC- 6400
Neutrophils- 56
Lymphocytes- 40
Eosinophils-2
Monocytes-2
Basophils-0
PCV- 28.9
MCV-64.9
MCH-21.0
MCHC-32.6
RDW-CV-17.1
RDW-SD-39.3
RBC COUNT-4.4
PLT- 1.6

BGT- B POSITIVE

ESR- 50

Serology- Negative

Serum electrolytes
Sodium- 143 
Potassium- 4.1
Chloride- 102

Liver function tests
Total biluribin- 0.80
Direct biluribin- 0.19
SGOT(AST)- 115
SGPT(ALT)- 100
ALP- 178
Total proteins- 6.9
Albumin- 3.45
A/G ratio- 1.00

Serum creatinine- 0.8

Blood urea- 30


Chest xray


ECG


USG abdomen


2D echo


Temperature charting

Treatment
1. IV fluids NS @ 75 ml/hr
2. Tab. PCM 650 mg PO/TID
3. Inj. PAN 40 mg IV/OD
4. Inj. Zofer 4 mg/IV/SOS
5. Inj. Neomol/IV/SOS
6. Plenty of oral fluids
7. BP, PR, RR monitoring

SOAP NOTES
Day 1 (28/10/22)
S
Fever
Headache
Body pains

O

Patient is conscious, coherent, cooperative
Temp - 100.2 F
BP- 110/70 mmHg'
PR- 84 bpm
RR- 18 cpm
SPO2- 94

A
Viral pyrexia

P

1. IV fluids NS @ 75 ml/hr
2. Tab. PCM 650 mg PO/TID
3. Inj. PAN 40 mg IV/OD
4. Inj. Zofer 4 mg/IV/SOS
5. Inj. Neomol/IV/SOS
6. Plenty of oral fluids
7. BP, PR, RR monitoring

Day 2 (29/10/22)
S
Fever
Headache
Body pains

O

Patient is conscious, coherent, cooperative
Temp - 100.8 F
BP- 110/80 mmHg'
PR- 82 bpm
RR- 22 cpm
SPO2- 96

A
Viral pyrexia

P

1. IV fluids NS @ 75 ml/hr
2. Tab. PCM 650 mg PO/TID
3. Inj. PAN 40 mg IV/OD
4. Inj. Zofer 4 mg/IV/SOS
5. Inj. Neomol/IV/SOS
6. Plenty of oral fluids
7. BP, PR, RR monitoring


Day 3 (30/10/22)
S
Fever
Headache
Body pains

O

Patient is conscious, coherent, cooperative
Temp - 99.8 F
BP- 110/80 mmHg'
PR- 85 bpm
RR- 21 cpm
SPO2- 95

A
Viral pyrexia

P

1. IV fluids NS @ 75 ml/hr
2. Tab. PCM 650 mg PO/TID
3. Inj. PAN 40 mg IV/OD
4. Inj. Zofer 4 mg/IV/SOS
5. Inj. Neomol/IV/SOS
6. Plenty of oral fluids
7. BP, PR, RR monitoring








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