65 year old female with cough-4 months and fever-10 days

 

Rachana Gangula 
Intern 

This is online E log book to discuss our patient’s 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 available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

 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 diagnosis and treatment plan. 



65 year old female with cough since 4 months and fever since 10 days 

CHIEF COMPLAINTS:


A 65 year old presented with cough since 4 months and fever since 10 days 



HISTORY OF PRESENT ILLNESS  

Patient was apparently asymptomatic 4 months back then developed cough associated with sputum , which is whitish in colour, thick, moderate amount, more during nights. 

H/o fever since 10 days, high grade a/w chills and rigor , internittent, no evening rise of temperature. 

No h/o cold, SOB, chest pain, palpitations, excessive sweating, burning micturition, pedal edema, decreased urine output

H/o increased exposure to dust 


PAST HISTORY 

Similar complaints in the past 20 years ago , and a/w itching of eyes and relieved with inj.Dexamethasone 

K/c/o TYPE 2 DM since 10 years ( gulcoryl- m1 1/2 tab in the morning and half in the night )

N/k/c/o htn, tb, asthma, thyroid disorder, epilepsy 

Personal history:-

Patient is moderately built and moderately nourished 

Diet: mixed 

Appetite: normal 

sleep: disturbed since last 10 days

Bowel and Bladder : regular bowel movements,  incresed frequency of urination during nights (5/night)

Addictions :- alcohol once in a month but stopped 1 year ago.

Tobbaco (chutta) since last 35 years daily one chutta 



General Physical Examination:-

Patient is conscious, coherent and cooperative and well oriented to time,  place and person. 


Pallor+ 



Icterus,cyanosis, clubbing, lymphadenopathy and edema are absent.

vitals:-

Temp:- 97.2 ⁰F

BP:- 120/80 mmhg 

RR:- 20 cpm

PR :- 78bpm 

Grbs :- 173 mg%






Systemic Examination 

Respiratory system:

BAE+ NVBS heard 

Wheeze in the right supra scapular area.

CVS- s1s2+ no murmurs 

Per Abdomen:

Shape is scaphoid

Abdomen is soft and non tender with no organomegaly

Bowel sounds are heard 

A vertical surgical scar present from below umbilicus to the pubis symphisis

? Laparotomy i/v/o abdominal mass 

CNS- NAD 


PROVISIONAL DIAGNOSIS  


LRTI ?PNEUMONIA .


Investigations:


ECG






CHEST X RAY



HEMOGRAM:- 

HB:-  10

TLC:- 11500

PCV:- 31.9

RBC:- 3.9

PLATELETS:- 3.5


CUE:- normal


PLBS:- 158 mg% 


Blood urea:- 39 mg/dl


Serum creatinine:- 0.9 mg/dl


Serum electrolytes:- 


Na+ : 139 mEq/L


K+ : 4 mEq/L


 Cl- : 102 mEq/L




DIAGNOSIS   


? Community Acquired Pneumonia 

? Pulmonary TB with rt upper lobe consolidation

K/c/o type 2 DM since 5 years.


TREATMENT 


1) Inj. AUGMENTIN 1.2 gm IV/BD for 5 days


2) Tab. AZITHROMYCIN PO/OD for 5 days


3) Tab. METFORMIN 500 mg + GLIMEPIRIDE 1mg PO/BD 1/2 tab










Comments

Post a Comment

Popular posts from this blog

INTERNSHIP ASSESSMENT

 INTERNSHIP ASSESSMENT  NAME- RACHANA GANGULA  ROLL NO- 117  This blog is my learning experience in medicine posting which was from 14/4/23 to 12/6/23  I CU ROTATION My first clinical rotation was in the peripheral postings, of which I started off my medicine posting in the Intensive care unit (ICU) for the first 5 days.  Spending time in the ICU afforded me to experience a wide range of what medicine has to offer; from simply keeping the heart and lungs functioning, to managing complex neurological disorders, to counseling entire families during the most difficult moments, there was no shortage of moments to learn from. And it left me a ton of crazy medical experiences.  Even though the ICU duty only last for a short amount of time, it is an opportunity to learn a lot of clinical skills. Starting with ICU made me dive head first into the critical care aspect of medicine, and it was a challenge to acclimatise so quickly to a fast paced environment.  However, even though it was initiall
Read more

48 Year old Male with bipedal edema RACHANA GANGULA INTERN

Image
This is an online E log book to discuss our patient's 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 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-centred online learning portfolio and your valuable comments on comment box is welcome.   48 year old man resident of Nalgonda and farmer by occupation came to the hospital with chief complaints of bilateral pedal oedema and sudden onset dyspnea around 3 months back and has been visiting the hospital for regular dialysis ever since then.  HOPI- Patient was apparently asymptotic 20 yrs back when he developed lower back pain for which he visited the hospital and was diagnosed with renal calculi and diabetes, for which he used medication for 3 years and under
Read more

50 year old man with altered sensorium, pain in abdomen and fever

  This is an online E log book to discuss our patient's 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 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-centred online learning portfolio and your valuable comments on comment box is welcome. 
Read more