CASES IN GENERAL MEDICINE
41-YEAR-OLD MALE PATIENT WITH A HISTORY OF FEVER AND ALTERED SENSORIUM
Hi, I am Ankesh Kumar Sahu a medical student. This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. This E-log book also reflects my patient-centered online learning profile and your valuable inputs on the comment box are 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.
CASE DISCUSSIOn
CASE: -
41year old male resident of Chalakurthy presented to the OPD in summer 2021 with chief complaints of
- Fever - Since 2 days.
- Altered sensorium with irrelevant talk-
Since 1 day.
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic
2days back then he developed high-grade fever with ear pain following which he
went to local RMP and had 2 injections. Since yesterday he had altered
sensorium with irrelevant talk.
FEVER
- High-grade fever
- Insidious in onset
- Intermittent in nature
- Duration = 2days
- Associated with Ear pain
- No
chills & rigor
- No
Aggravating factors
- Relieved
by taking Antipyretic.
PAST
HISTORY
* He is a known case of
Diabetes mellitus and Hypertension since 2 years.
* No history of Asthma,
Thyroid, Tuberculosis, Epilepsy & CVS problems.
* History of head injury two
and half years back was in a coma for 20 days followed by abnormal behavior.
DRUG HISTORY
* D.M = No medications taken.
* HTN = Tab. Telmisartan 40mg
OD
Tab. Cilnidipine 5mg OD
*Abnormal behavior
Tab. Escitalopram.
PERSONAL HISTORY
* Diet = Mixed
* Appetite = Normal
* Bowel and Bladder = Regular
* Sleep = Adequate
* No Addictions
* No Drug Allergies
FAMILY HISTORY
* Father had a history of Diabetes mellitus
and Hypertension.
GENERAL EXAMINATION
* Patient was examined in well light and good
ventilation room.
*Patient has altered sensorium and not
responding to commands.
* Moderately built and Moderately nourishment.
No Pallor
No Icterus
No Cyanosis
No Clubbing
No Bilateral pedal edema
No Lymphadenopathy.
* Mild dehydration present
Vitals at the time of
admission
JUNE 01 2021
Temperature = 100.3 F
Pulse rate = 18 cycles per min
Respiratory rate = 80
beats/min
Blood pressure = 140/70 mm of
Hg
Spo2 = 99% at room air
GRBS = 143 mg/dl.
VITALS ON JUNE 02 2021
*Temperature = 98.4 F
Pulse rate = 21 cycles per min
Respiratory rate = 86 beats per min
Blood pressure = 110/60 mm of Hg
Spo2 = 97% at room air
GRBS = 189mg/dl.
VITAL ON
JUNE 03 2021
Temperature = 97 F
Pulse rate = 97beats per min
Blood pressure = 110/80 mm of
Hg
Spo2 = 98 % at room air
GRBS = 167 mg/dl
VITALS ON JUNE 04 2021
Temperature = Febrile
Pulse rate = 68 beats Per min
Blood pressure = 120/80 mm of Hg
TPR GRAPHIC SHEET
SYSTEMIC EXAMINATION
* CVS - S1, S2
sounds heard
No murmurs.
* Respiratory system
~Normal vesicular breath sounds heard
~ Bilateral air entry present (BAE+ve)
* Abdomen
Soft and Tender
Bowel
sounds normal
No
Organomegaly.
* CNS
# Level of consciousness – Drowsy,
Arousable
# Speech - Incoherent
# No meningeal irritation
# Muscle tone - Normal
# Muscle power -5/5
# Glasgow scale - Altered.
INVESTIGATIONS
Complete
Blood Picture (CBP)
* Hemoglobin = 12 gm /dl
* TLC = 25,000
* DLC
- Neutrophils = 90%
-Lymphocytes = 04%
-Eosinophils = 02%
-Monocytes = 02%
-Basophils = 00%
* Platelets = Adequate
June 02, 2021
June 04
2021
HEMOGRAM
LIVER FUNCTION TEST (LFT)
* Total bilirubin - 1.62 mg/d1
* Direct bilirubin - 0.74
mg/dl
* AST (SGOT) - 25 IU/L
* ALT (SGPT) - 12 IU/L
* Alkaline phosphatase - 79
IU/L
* Total proteins -6.5 gm/dl
* Albumin - 3.5 gm/dl
* A/G ratio -1.20
RENAL FUNCTION TEST
* Urea =
36mg/dl
* Creatinine =
0.8mg/dl
* Uric acid.
= 4.3mg/dl
* Calcium.
= 9.6 mg/dl
* Phosphorus. = 2.0 mg/dl
* Sodium.
= 136 mEq/L
* Potassium.
= 38 mEq/L
* Chloride.
= 92 mEq/L
BLOOD SUGAR FASTING
June 02, 2021
June 04
2021
BACTERIAL
AND SENSITIVITY REPORT
June 03
2021
June 04
2021
ECG
REPORT
Patient referred to: -
Psychiatry (on June 01, 2021)
With chief complaints of -
* Altered sensorium with the irrelevant talk since 1day
* History of head injury 21/2 yrs. back.
Diagnosis: -
Treatment: -
Inj. Lorazepam
1/2amp /iv sos
Tab. Nexito plus @ 8:30 pm OD.
DVL (on June 04, 2021)
With chief complaints of: -
* Vesicular lesions on
lips and face
(cheek) since 3 days.
# History of similar
complaints in the past.
Diagnosis:
-
Treatment:-
CALAMINE LOTION BID,7days
EUDIC CREAM (on raw areas) BID 7days
Tab. Zincovit OD 30 days.
PROVISIONAL DIAGNOSIS
Viral pyrexia, secondary
to Adjustment personality disorder with HTN & DM.
TREATMENT HISTORY
JUNE 01 2021
Inj. Pantop 40mg /iv/ OD
Inj. Ceftriaxone 1gm / iv / OD
Inj. Zofer 4mg /iv/ TID
Inj. Thiamine 200mg /iv/TID
Tab. Paracetamol 650mg /po/TID
Tab. Cilnidipine 10mg / po / OD
IVF (N.S & RL) @ UO /50ml per hr.
JUNE 02 2021
Inj. Pantop 40mg /iv/ OD
Inj. Ceftriaxone 1gm / iv / OD
Inj. Zofer 4mg /iv/ TID
Inj. Thiamine 200mg /iv/TID
Tab. Paracetamol 650mg /po/TID
Tab. Cilnidipine 10mg / po / OD
Inj. NEOMAL 100ml / iv / sos if tem >102F
IVF (N.S & RL) @ UO /50ml per hr.
Inj. Lorazepam 1/2 amp iv/ sos
Tab. NEXITOPLUS @ 8:30pm OD
JUNE 03 2021
Inj. Pantop 40mg /iv/ OD
Inj. Ceftriaxone 1gm / iv / BD
Inj. Zofer 4mg /iv/ TID
Inj. Thiamine 200mg /iv/TID
Tab. Paracetamol 650mg /po/TID
Tab. Cilnidipine 10mg / po / OD
Inj. NEOMAL 100ml / iv / sos
Inj. Lorazepam 1/2 amp iv/ sos
Tab. NEXITOPLUS @ 8:30 pm OD
JUNE 04 2021
Inj.Pantop 40mg /iv/ OD
Inj.Ceftriaxone 1gm / iv / BD
Inj .Zofer 4mg /iv/ TID
Inj. Thiamine 200mg /iv/TID
Tab. Paracetamol 650mg /po/TID
Tab. Cilnidipine 10mg / po / OD
Inj. NEOMAL 100ml / iv / sos
Inj.Lorazepam 1/2 amp iv/ sos
Tab.NEXITOPLUS @ 8:30 pm OD
CALAMINE LOTION BID ,7days
EUDIC CREAM ( on raw areas ) BID 7days
Tab.Zincovit OD 30 days.
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