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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.
A 70 year old female patient came to the OPD with chief complaints of fever since 3 days and polyuria since 3 days.
Patient was apparently asymptomatic 3 days back then she developed fever associated with chills and rigor present throughout the day relieved after taking medication
No diurnal variation
No C/O cough ,shortness of breath
C/O headache since 3 days(diffuse type)
C/O decreased appetite since 3 days nausea vomiting.
Patient was taken to katangur 3 days back given some medication and was told she has high sugar (300 mg/dl)
No H/O chest pain
No H/O palpitation
No H/O burning micturition
No H/O pedal edema
PAST ILLNESS-
k/c/o DM, HTN since 3 months.
TREATMENT HISTORY-
T. METFORMIN 500 mg/ po/BD.
T. ATEN 50/ po/ BD.
PERSONAL HISTORY-
Is married and daily wage labourer
Appetite -normal
Vegetarian
Bowel and bladder movements are regular
No known allergies
No Addictions
FAMILY HISTORY-
• Has no family history of DM, HTN, asthma, TB, CAD, strokes, cancers, heart diseases.
GENERAL EXAMINATION-
• Pallor - no
• No cyanosis, icterus
• No lymphadenopathy, clubbing of fingers/toes, no oedema of feet, no malnutrition.
• Dehydration - mild
Vitals :
• PR - 98bpm ( irregular)
• RR - 22 cycles/min
• BP - 110/80 mmHg
• Temp. 103.3°F
• GRBS - 110 mg/dl
• SPO2- 81%
SYSTEMIC EXAMINATION-
A. Cardiovascular system :
• S1, S2 are heard
• No thrills and no cardiac murmurs
B. Respiratory system:
• No dyspnoea, no wheezing
• Position of trachea - central
• Breath sounds - Vesicular
• Crypts over left inferior and anterior area heard
C. Per Abdominal Examination:
• Shape of abdomen - scaphoid
• No Tenderness
• No palpable mass , free fluids, bruits
• Liver, spleen not palpable
• Bowel sounds-present
D. Central Nervous system Examination:
• Pt is conscious
• Speech normal
• No neck stiffness, kerning's sign.
DIAGNOSIS-
Viral pyrexia
INVESTIGATION
On 07/08/2021.
Ultra sound:-
Fever chart:-
From 07/08/21 to 14/08/21
On 09/08/21.
On 12/08/21
FINAL DIAGNOSIS:ENTERIC FEVER
Treatment:-
Day 1 :- 07/08/2021
1) IVF - RL
} @50ml/hr
- NS
2) TAB.PAN - 40mg/PO/OD
3) TAB.ZOFER - 4mg/IV/SOS
4) TAB.DOLO - 650mg/PO/DD
1------ 1-------1
5) TAB.AZITHROMYCIN- 500mg/PO/OD
1------X-------X
6) ING. NEOMOL -100 ml/IV/SOS
(If Temp>101.1F°)
7) O2 Inhalation if SP O2 < 90% of room air.
Day2:- 08/08/2021
1) IVF - RL
} @75ml/hr
- NS
2) INJ.MONOCEF 1ml/IV/SOS
3) TAB.AZITHROMYCIN- 500mg/PO/OD
1------X-------X
4) TAB.PAN - 40mg/PO/OD
5) TAB.ZOFER - 4mg/IV/SOS
6) TAB.DOLO - 650mg/PO/DD
1------ 1-------1
7) O2 Inhalation if SP O2 < 90% of room air.
DAY 3
SUBJECTIVE:
Pt c/o nausea
OBJECTIVE
Temperature-101 F
Bp-110/60 mmhg
PR- 86bpm
RR -17 cpm
Grbs-144 mg/dl
ASSESSMENT-
Viral pyrexia
K/c/o DM & HTN (10yr's)
PLAN OF CARE-
1.INJ.MONOCEF 1gm/iv/bd
2.TAB.Azithromycin 500 mg/po/BD
3.Tab.PCM PO/TID
4. Tepid sponging
5. GRBS Charting 6th hrly
6. O2 Inhalation if SP O2 < 90% of room air.
7.Temperature charting 1hrly.
8. strict I/O charting.
SOAP NOTES DAY 4
A 70 YEAR OLD FEMALE WITH VIRAL PYREXIA
SUBJECTIVE:
Pt C/o fever
C/o weakness
OBJECTIVE:
Temperature-98.5 F
Bp-110/70 mmhg
PR- 78bpm
RR -23 cpm
Grbs-132 mg/dl
ASSESSMENT-
Viral pyrexia
K/c/o DM & HTN (10yr's)
PLAN OF CARE-
1.INJ.MONOCEF 1gm/iv/bd
2.TAB.Azithromycin 500 mg/po/BD
3.Tab.PCM PO/TID
4. Tepid sponging
5. GRBS Charting 6th hrly
6. O2 Inhalation if SP O2 < 90% of room air.
7.Temperature charting 1hrly.
8. strict I/O charting.
SOAP NOTES DAY 5 :
A 70 YEAR OLD FEMALE WITH VIRAL PYREXIA
SUBJECTIVE:
Pt C/o fever
C/o weakness
OBJECTIVE:
Temperature-98.7 F
Bp-110/60 mmhg
PR- 81 bpm
RR -21 cpm
Grbs-172 mg/dl
ASSESSMENT-
Viral pyrexia
K/c/o DM & HTN (10yr's)
PLAN OF CARE-
1.INJ.MONOCEF 1gm/iv/bd
2.TAB.Azithromycin 500 mg/po/BD
3.Tab.PCM PO/TID
4. Tepid sponging
5. GRBS Charting 6th hrly
6. O2 Inhalation if SP O2 < 90% of room air.
7.Temperature charting 1hrly.
8. strict I/O charting.
Day 6: 12/08/21
A 70 YEAR OLD FEMALE WITH VIRAL PYREXIA
SUBJECTIVE:
C/o weakness
OBJECTIVE:
Temperature-98.6 F
Bp-110/60 mmhg
PR- 90 bpm
RR -21 cpm
Grbs-153 mg/dl
ASSESSMENT-
Viral pyrexia
K/c/o DM & HTN (10yr's)
PLAN OF CARE-
1.INJ.MONOCEF 1gm/iv/bd
2.Tab.Pan 40 mg po/od
3. Tab zofer 4 mg iv/bd
4. Tab dolo 650 mg po/TID
5. GRBS Charting 6th hrly
6. O2 Inhalation if SP O2 < 90% of room air.
7.Temperature charting 1hrly.
8. strict I/O charting.
Day 7 :13/8/21
A 70 YEAR OLD FEMALE WITH VIRAL PYREXIA
SUBJECTIVE:
C/o weakness
OBJECTIVE:
Temperature-98.6 F
Bp-90/60 mmhg
PR- 80 bpm
RR -21 cpm
Grbs-123 mg/dl
ASSESSMENT-
Viral pyrexia
K/c/o DM & HTN (10yr's)
PLAN OF CARE-
1.INJ.MONOCEF 1gm/iv/bd
2.Tab.Pan 40 mg po/od
3. Tab zofer 4 mg iv/bd
4. Tab dolo 650 mg po/TID
5. GRBS Charting 6th hrly
6. O2 Inhalation if SP O2 < 90% of room air.
7.Temperature charting 1hrly.
8. strict I/O charting.
Course in hospital-
75 yr old female admitted with complaints of fever from 3 days. Fever was intermittent type associated with chills and rigors. Along with fever pt also had complaints of shortness of breath,headache,loss of apetite.
Pt was managed conservatively with initial suspicion of viral pyrexia with no favourable response and no positive diagnostic test.Pt was given empirical antibiotic therapy and
fever subsided. It showed a typical step ladder pattern confirming diagnosis of Enteric Fever. With improvement in overall condition and resolution of above mentioned symptoms pt is being discharged with following medication and adviced for follow up after 1 week.
Advice at discharge
T Cefixime 200mg BD for 5 days
T pan 40 mg once daily for 5 days
T PCM 650mg sos
T MVT once daily for 5 days
T.metformin 500 mg once daily
