40 year old male presenting with fever and headache

 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-centered online learning portfolio and your valuable inputs on the comment box. 

Chief complaints

>fever since 3 days

>headache since 2 days

History of presenting Illness

Patient was apparently asymptomatic 3 days ago then developed fever, high grade a/w chills, not associated with diurnal variation, relieving on medication

H/O headache present since 2 days in frontal region, continuous, 

No H/O vomiting, loose stools

No H/O nausea, abdominal distension

No H/O rash, chough, cold

No H/O burning mituration, dysurea

Past H/O

Not a K/C/O DM, HTN, thyroid disease, BA

PERSONAL HISTORY :

DIET - MIXED

APPETITE -NORMAL ,

BOWEL MOVEMENT - REGULAR , 

BLADDER MOVEMENTS - REGULAR, 

ALCOHOL ADDICTION, LAST BINGE 3 DAYS BACK 60 ML WHISKY

FAMILY HISTORY - 

NAD

ON EXAMINATION -

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA

VITALS - 

TEMPERATURE - 99.1

PULSE RATE - 84 BPM

BLOOD PRESSURE - 110/70 MM OF HG 

RESPIRATORY RATE - 16

SPO2 - 99 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

Investigations

ECG

                                      Normal sinus rhythm

Chest X-ray

CUE (2/3/22)

Albumin: +

Sugar: ++++

Pus cells: 4-5

Epithelial cells: 3-4 

HEMOGRAM

HB 14.3

TC 2800

PLT 92000

MCV 80.2

PCV 41.2

MCH 27.5

MCH 34.3

SMEAR - NORMOCYTIC NORMOCHROMIC, WITH BICYTOPENIA

SMEAR FOR MALARIAL PARASITE - Negative

BGT - O +ve

CUE

ALB - trace

Sugar - nil

Puscells - 2-4

Epithelial cells - 2-4

HbSAg - negative

HCV - negative

HIV - negative

Dengue serology

NS1 - +ve

IgG - negative

IgM - negative

RFT

Urea- 22

Creatinine-0.9

UA-4.1

Calcium-9.2

Phosphorus-2.5

Sodium-136

Potassium-3.8

Chloride-102

LFT

TB-1.37

DB-0.47

AST-84

ALT-49

ALP-168

TP-56

ALB-3.31

Diagnosis

Viral pyrexia

Treatment

Inj. Paracetamol 1g IV Stat

IVF  NS/RL at 75ml/hr

T. Paracetamol 650mg PO TID

Day 1

Day 2 SOAP NOTES

3/3/22

S-C/o headache, neck pain subsided, one fever spikes today

O-

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA

VITALS - 

TEMPERATURE - 98.1

PULSE RATE - 75 BPM

BLOOD PRESSURE - 120/80 MM OF HG 

RESPIRATORY RATE - 17

SPO2 - 100 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

HEMOGRAM

HB 16

TLC 3000

PCV 46.6

MCV 82.9

MCH 28.9

MCHC 34.2

Plt 90,000

P. S normocytic, normochromic with bicytopenia

A-

viral pyrexia with thrombocytopenia with NS1 POSITIVE

P-

Inj. Optineuron in 100ml NS over 30 mins

IVF NS/RL at 150ml/hr

T. Paracetamol 650mg PO TID

SOAP NOTES DAY 3

4/3/22

S-C/o headache,neck pain subsided, no fever spikes today

O-

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA, no petichiae

VITALS - 

TEMPERATURE - 98.3

PULSE RATE - 82 BPM

BLOOD PRESSURE - 

110/70 MM OF HG supine

110/70 mmHg standing

RESPIRATORY RATE - 19

SPO2 - 99 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

HEMOGRAM

HB 15.9

TLC 2300

PCV 46.3

MCV 82.9 

Plt 50,000

P. S NORMOCYTIC NORMOCHROMIC WITH neutropenia and thrombocytopenia

A-

viral pyrexia with thrombocytopenia with NS1 POSITIVE

P-

Inj. Optineuron in 100ml NS over 30 mins

IVF NS/RL at 150ml/hr

T. Paracetamol 650mg PO TID

SOAP NOTES DAY 4

5/3/22

S-C/o headache,neck pain subsided, no fever spikes today

O-

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA, no petichiae

VITALS - 

TEMPERATURE - 96.9

PULSE RATE - 85 BPM

BLOOD PRESSURE - 

110/70 MM OF HG supine

110/70 mmHg standing

RESPIRATORY RATE - 19

SPO2 - 98 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

HEMOGRAM

HB 15.1

TLC 2900

PCV 45.2

MCV 80.9 

Plt 41,000

P. S NORMOCYTIC NORMOCHROMIC WITH neutropenia and thrombocytopenia

Platlet count

Day 1 - 92,000

Day 2 - 90,000

Day 3 - 50,000

Day 4 - 41,000

A-

viral pyrexia with thrombocytopenia with NS1 POSITIVE

P-

Inj. Optineuron in 100ml NS over 30 mins

IVF NS/RL at 150ml/hr

T. Paracetamol 650mg PO TID

55 year old presenting with fever,sob

 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 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 inputs on the 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 a diagnosis and treatment plan

55 year old female came with chief complaints of 

• Fever since 4 days

• SOB since 4 days

HOPI:  The patient was apparently asymptomatic 4 days back , then developed  she had a H/o RTA ( Fracture of left lowerlimb) S/p wound debridement with external fixator under spinal anaesthesia)

H/o pus discharge from external fixator site.

Grade 4 SOB progressive in nature ( At rest) a/w lower back ache and generalised body pains.

 , progressive in nature

, high grade , relieved on medication.

PAST HISTORY:  k/c/o Diabetes mellitus 2

Not a K/c/o HTN, TB,CVA ,CAD ,Epilepsy ,Asthma

PERSONAL HISTORY:

Diet: Mixed

Appetite: Normal

B&B: Regular 

Addictions: No addictions.

O/E

General examination 

Temp: 98.9 F

PR: 100 bpm

BP: 130/90 mm hg

RR:  22 cpm

SpO2: 98% @ RA

GRBS: 387 mg / dl

Systemic examination 

CVS: S1S2 + , No murmurs

RS: BAE + , NVBS

P/A: Soft , NT

CNS:  No FND

INVESTIGATIONS

TREATMENT:

IVF NS & RL continuous infusion @ 180 ml/hr

Inj. HAI 8 units/IV/STAT

Inj. HAI 10 ml in 39 ml NS IV @ 6ml/hr

Inj. MEROPENEM 1gm IV/BD

Inj. VANCOMYCIN 1 gm in 100 ml NS IV/BD

Inj. PAN 40mg IV/OD

GRBS Monitoring hourly 

IVF 25% Dextrose if GRBS is more than 150 mg/dl.

Prefinal examination

Paper 1- prefinal

Date -03/01/22

Question no.1

 

Question no.2

Question no.3

Question no. 5

Question no.6

Question no.8

Very shorts - 

Question no.9

Question no.10

Question no.16

Prefinal paper 2

Date : 04/01/22

55 year old male patient presenting with abdominal pain and chest pain

 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-centered online learning portfolio and your valuable inputs on the comment box.

Chief complaints : 

Abdominal pain since 5 days 

Breathing difficulty since  2 days 

History of present illness: 

Patient was apparently asymptomatic 5 days back then he developed abdominal pain after taking alcohol continuously for 3 days . It is sudden in onset and gradually progressive and dragging type which is aggravated on alcohol intake and relieved on medication. Previously visited other hospitals , after onset of abdominal pain but it didn't relieve inspite of medication .

There is h/o altered sensorium since 3 days . He is unable to identify his wife and pulling away the cannulas.

There is history of nausea where he vomited by inducing with his hand . 

There is history of weight loss also since 1 year. 

History of sob which is grade 4 

History of fever yesterday.

Past history: 

A known case of diabetes since 2 years on medication .

History of TB diagnosed 2 months back on regular medication.

Not a known case hypertension,asthma,epilepsy,CVD.

Personal history: 

Bowel and bladder - regular and there is increased frequency of urine seen when sugar levels are increased .

Not sleeping adequately since 2 days 

Alcohol consumption since 30 yrs occasionally for festivals but he drinks  continuously for 3 days of 1 full bottle quantity.

History of tobacco smoking since 25 yrs.

Family history: 

Not significant

General examination:

Patient is conscious ,not co operative ,not oriented to time place person 

Not well built and nourished .

Afebrile

GCS : 

          EYE OPENING :4 (opened spontaneously)

          VERBAL RESPONSE: 3

           MOTOR RESPONSE :3 

                        Total :10

        Pallor : present

        Icterus : absent

        Cyanosis : absent

        Clubbing : absent 

        Lymphadenopathy : absent 

Vitals:-

Pulse - 90bpm 

RR - 22 cpm

Bp- 140 / 70 mm hg 

Temperature- 97.4°c 

Spo2- 99%at RA.

GRBS

5:30-600

7:30- 390

8:30-380

9:30- 383

10:30- 382

11:30- 260

12:30- 210

1:30- 220

2:30- 206

3:30- 207

4:30- 147

5:30- 77

6:30- 121

7:30- 131

Systemic examination:-

Examination of oral  cavity- 

No dental caries, no gum hypertrophy , oral hygiene is maintained , no postnasal drip 

Abdominal examination- 

INSPECTION:

Shape – scaphoid, flat,not distended

Flanks – free 

Umbilicus – Position- central, Shape-inverted

Skin –  No scars, no sinuses,no striae, no nodules,no  scratch marks,

Dilated veins – not present 

All quadrants  are equally Movable with respiration  ,no visible gastric peristalsis.

No abdominal distension .

PALPATION:

No local raise of temperature.

Superficial Palpation – Tenderness not elicited.

Deep Palpation-

Liver-

Not palpable

Spleen-

Not palpable

Kidney-

Bimanually Not palpable

PERCUSSION:

Fluid Thrill/Shifting dullness/Puddle’s sign - not elicited

Liver span - 6cm 

AUSCULTATION:

Bowel sounds are heard.

EXAMINATION OF OTHER SYSTEMS

CARDIOVASCULAR SYSTEM:

S1, S2 are heard.

EXAMINATION OF RESPIRATORY SYSTEM:

Normal vesicular breath sounds heard.

EXAMINATION OF NERVOUS SYSTEM:

Altered sensorium, irrelevant talking and unable to recognise his wife and He is pulling away the cannula.

On 9 th jan :

INVESTIGATIONS:-

Usg report-

On 11 Jan : 

Patient reviewed 

Pain decreased yesterday denies for alcohol cravings.

On examination- patient drowsy

Bp - 110/70 mmHg 

PR-102 / min

SpO2 - 98% on room air 

 

Lab investigations- 

ABG analysis: 

pH -7.44

PCo2 - 25.3 

HCO3 - 17.1 

 

Serum urea - 47 

Serum creatinine- 0.8 

Na+ - 133 

K+ - 3.2 

Cl-  - 94

Treatment:-

1. IVF- NS- 1L for 3hrs.

2. Inj HAI 6IU IV/STAT.

3. GRBS monitoring hrly.

4.IVF-5% Dextrose if GRBS<250mg/dl.

5.Inj THIAMINE 100mg in 100 ml NS/IV/BD.

6.Inj OPTINEURON 1 amp in 100ml NS/IV/OD.

PROVISIONAL DIAGNOSIS:-

Diabetic ketoacidosis with known case of diabetes milletus.