GENERAL MEDICINE CASE PRESENTATION

 This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect current best evidence based input

This Elog also reflects my patient centered online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever .

A 60 Year old female came to the OPD with the 

CHIEF COMPLAINTS:

Fever since 10 days 

Pain abdomen since 5 days  

HOPI:

The patiet was apparently aysmptomatic 10 days back later she developed Fever with chills and rigors, intermittent ,low grade ,associated with chills and generalised weakness

not associated with evening rise of temperature

she went to a local hospital and has taken some injections and her fever got relieved.

after a day ,she had another episode of fever for which she was admitted

 in a local government hospital .

History of pain abdomen in the epigastric region since 5 days seassociated with abdominal distension which was sudden in onset non progressive,non radiating associated with an episode of vomiting.

complaining of involuntary movements of both the upper limbs since 6 days. 

patient had constipation 2 days back and the patient passed stool today.

she haven't had alochol since her fever started except on August 12th in a social gathering.

she is experiencing tremours and sleep disturbances if she did not consume alcohol.

HISTORY OF PAST ILLNESS:

Patient is an alcoholic since 15 years

consumes about 6-12 units everyday.

Not a K/C/O Diabetes,

HTN, TB , ASTHMA , EPILEPSY.

GENERAL EXAMINATION:

patient is concious , coherent and cooperative

PALLOR - Absent

ICTERUS- absent 

CYANOSIS - absent 

CLUBBING- absent 

LYMPHADENOPATHY- absent 

EDEMA- Absent 

SYSTEMIC EXAMINATION:

RS: BAE +

 Normal vesicular breath sounds , 

No crepts , no wheeze.

CVS - S1 and S2 +

CNS - NAD 

P/A- soft and non tender. 

VITALS :

BP-130/90 mm Hg

PR-96bpm

RR-26cpm

Temp-98.6°F

GRBS- 8am-89mg/dl

PROVISIONAL DIAGNOSIS:

ACALCULOUS CHOLECYSTITIS WITH DENGUE 

Alcohol dependence syndrome.

TREATMENT:

NBM- till further orders.

IVF - NS ,RL @100 ml/hr.

INJ - Monocef 1gm IV BD.

INJ- METROGYL 100ml IV BD.

Inj - PAN 40 mg IV OD 

INJ - PCM 1gm IV TID.

INJ - ZOFER 4mg IV SOS 

INJ - THIAMINE 200mg IV BD 

Ta

B - LORAZEPAM 2mg PO TID