General medicine case history
This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment
This e blog also reflects my patients centered online learning portfolio and your valuable inputs on the comment box is welcome.
Introduction
A 26 yr old male patient came to causality on 18/12/21 from nakerekal with the complaints of fever with chills, cough and breathlessness since 3 days and vomiting since 1day
History of present Illness
Patient was apparently asymptomatic 5 months back.
4 months back under the influence of alcohol he had a history of fall from bike and at the time of fall he had sustained head injury with no history of consciousness, ent bleeding and then he was admitted to local hospital there while he was receiving the treatment he developed fever with chills, cough with sputum, and bipedal edema and then he was admitted to the kims. And he received the treatment for about 10 days and later his symptoms subsided and he was discharged.
In between duration gap between these august and the date of admission he developed the same episodes of symptoms for about 3times then he consulted a local doctor (RMP) and later the symptoms subsided on taking medication.
3days back patient developed fever with chills, cough with sputum, and shortness of breath (grade-3) and before the admission-1 he had history of vomiting which is in bilious colour
Sob aggravates on lying down position and relieves when he turned to one side.
Patient gave a history of consanguineous marriage of his parents And he was diagnosed with dextrocardia on the 4th day of his birth for which he was given treatment and later he was discharged after reliving the symptoms
History ofpastillnes
No history of diabetes , hypertension, asthma, tuberculosis and epilepsy
Personal history
No loss of apetite
Diet:mixed
No sleep disturbances
Bowel and bladder movements :-normal
Patient has history of consuming alcohol (90ml per day) and now he withdrawn the habit
No history of smoking
Family history
No similar complaints in the family
General examination
Patient is concious, coherent, and cooperative
No pallor
No icterus
No clubbing
No cyanosis
No regional lympadenopathy
Vitals:-
Temperature :-99.3F
Respiratory rate:-38cycles/min
Pulse rate :-104beats/min
Blood pressure:-90/60mmHg
Urea-37mg/dl
Creatinine-1.1mg/dl
Serum electrolytes
Calcium-10.2mg/dl
Sodium-140mEq/L
Pottasium-5.5mEq/L
Chloride-92mEq/L
TREATMENT
Neb-budecort-12th hourly
-ipravent-8th hourly
Inj Lasix 20mg/IV/BD
Inj PANTOP 40mg/IV/OD
Inj NORAD 2amp in 48ml normal saline
Inj Augmentin 1.2gm/IV/BD
Tab Azithromycin 500mg/PO/OD
Tab Paracetamol 650mg
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