42 years female with fever and vomitings


​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


M kalpana

9th sem


Case history : 

42 years old female patient who works at gram panchayat came to the hospital with chief complaints of

 fever , nausea , constipation ,vomitings, generalised weakness since 7days 

burning micturition since 1day 


HOPI- 

Patient was apparently asymptomatic 1week back when she developed fever, which is intermittent, not associated with chills , rigors , associated with generalised weakness. Its also associated with nausea , constipation , passing flatus. 


Patient also complaints of nausea associated with one spontaneous episode of vomiting. Following which the patient stimulated vomiting by herself whenever she feels nauseating. 

No c/o loose stools.

C/o burning micturition since 1day .

Dry cough since 1day 

No c/o sputum , SOB , bleeding manifestations.


Not a k/c/o DM , HTN ,TB, Asthma , CAD 

​

Personal history -

Diet - mixed

Appetite - Decreased 

Sleep - Adequate 

Bowel and bladder movements-- constipation 

Rashes and itching on eating non veg .

No addictions .


Family history - not significant.


GENERAL EXAMINATION

Patient is conscious

Oriented

Co-operative

Moderately built,Well Nourished

Palor-absent

Icterus-absent

Cyanosis – absent 

Clubbing- absent

Pedal edema – absent

Lymphadenopathy- absent


Vitals:  


PULSE RATE- 100 beats / minute,regular rhythm, normal volume and character, no radioradial delay, normal condition of vessel 


BLOOD PRESSURE: 110/70 mm of Hg measured in the left Upper limb with the patient in supine position


RESPIRATORY RATE: 26 cycles/min, type-thoracoabdominal


TEMPERATURE: 98 F 



SYSTEMIC EXAMINATION



ABDOMEN:

INSPECTION:

Shape of abdomen – generalised fullness due to fat 

Umbilicus –central in position ,inverted

Skin – no scars, sinuses,dilated veins 

Movements of the abdominal wall -moves with respiration 

No visible gastric and intestinal peristalsis


PALPATION:


Superficial Palpation – No tenderness and no local rise of temperature


Deep Palpation

No significant organomegaly


Measurements - Abdominal Girth-90cms, Distance between the  Xiphisternum-Umbilicus -18 cms Umbilicus-Pubic Symphysis-22 cms 

  

PERCUSSION:

Percussion of Liver for Liver Span-12cms


AUSCULTATION:

Bowel sounds –audible in right iliac fossa

Bruit -absent


Cns examination

Higher mental functions -intact

Cranial nerve examination -normal 

Motor  system examination-

Bulk- normal  in all muscles

Tone -normal in all muscles

Power -5/5 in all muscles

Superficial &deep reflexes present

Sensory system examination-

Pain ,temperature ,touch ,vibration sensations present two point discrimination & tactile localisation present

Cerebellar functions -normal


Respiratory system examination-

Inspection-

Upper respiratory tract -no significant findings

Lower respiratory tract

Position of trachea -midline 

Chest -symmetrical

Movement of chest- equal on both sides with respiration

No visible dilatation of veins ,scars, sinuses

 Palpation-

Trachea is in midline

Chest expansion - normal , equal on both sides

Vocal fremitus -equal on both sides


Cvs examination-


JUGULAR VENOUS PULSE: 

INSPECTION:

Chest wall elliptical in shape and symmetrical,

Precordial bulge absent 

Dilated veins, scars, sinuses absent

Apical impulse not seen

Pulsations – no visible pulsations


PALPATION:

Apical impulse – normal in left 5th ics , 1cm medial to midclavicular line.

    No parasternal Heave or thrills

PERCUSSION:


AUSCULTATION: 

S1 S2 heart sounds are heard 

No abnormal heart sounds heard.









Investigations:


Complete blood picture-

​


Urine examination-


Blood urea-



NS1 antigen-



Serum electrolytes-



Serum creatinine-


Ultrasound abdomen-


ECG-



Diagnosis-

Fever under evaluation


Treatment -

IVF -NS,RL,DNS @75ML)HR

INJ PANTOP 40MG IV OD

INJ ZOFER 4MG IV SOS 

INJ OPTINEURON 1AMP IN 100ML NS IV OD 

INJ NEOMOL 1GM IV SOS (IF TEMP >101°F)

TAB DOLO 650 MG PO SOS

SYP LACTULOSE 10ML PO H/S


















​




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