Skip to main content

GM CASE DISCUSSION

 

August 03, 2021

A 15YR BOY WITH COMPLAINTS OF FEVER

 A 15year old male patient resident of Narketpalli came to the opd with the chief complaints of 

-fever since 4 days

History of presenting Illness-

Patient was apparently asymptomatic since 4 days back when he developed fever  which was sudden in onset,intermittent,low grade, associated with chills and was relieved on  medication.

-No H/O vomitings 

-No H/O cold,cough,headache,sob

-No H/O rash,pain abdomen ,loose stools ,constipation

- No H/O burning micturition 


Past Illness - No h/o Diabetes, Hypertension, Tuberculosis, Epilepsy, Thyroid,Asthma, CAD,CVD. 

Personal History-
Mixed diet 
Normal appetite 
Adequate sleep 
Regular bladder and bowel movements 
No addictions 

Family History- No similar complains in the family.
No history of Diabetes, Hypertension,TB, Asthma, CAD,CVD.

General Examination-
Patient was conscious, coherent, co- operative. Well oriented to time, place and person.

Moderately built and moderately nourished .

No pallor
No icterus
No clubbing
No cyanosis
No lymphadenopathy 
No edema 

VITALS-

TEMPERATURE-97.6 C/F
BP-100/70mm of hg
PR-80 BPM
RR-18 CPM
SPO2- 98% at Room air
GRBS- 125 mg/dl

SYSTEMIC EXAMINATION-

CVS EXAMINATION-
S1, S2 heard
No murmurs
Apical impulse at 5th intercoastal space lateral to mid clavicular line

RESPIRATORY SYSTEM EXAMINATION- 
Trachea-midline
Bilateral air entry present 
Normal vesicular breath sounds heard
No additional sounds

PER ABDOMINAL EXAMINATION-

INSPECTION-
Shape- Scaphoid 
Umbilicus- central and inverted
Movements with respiration- equal in all quadrants, rises with inspiration and falls during expiration 
No visible pulsations 
No visible scars or sinuses seen 
No engorged veins 
PALPATION-
No local rise of temperature 
No tenderness in any quadrants of abdomen
Liver and spleen- impalpable( no organomegaly)
PERCUSSION-
Tympanic note 
AUSCULTATION-
Bowel sounds present

CNS EXAMINATION-
Gait -normal
Sensations - present
Cranial nerves- intact
Reflexes- preserved

Investigations









PROBABLE DIAGNOSIS-
 FEVER WITH THROMBOCYTOPENIA.

TREATMENT GIVEN-
1. Continuous infusion of fluids RL and NS @ 100 ml/hr
2.Inj.Optineuron 1amp in 100 ml NS IV/ OD
3.Tab.Pan 40mg/OD
4.Tab.Dolo 500mg/BD

Comments

Post a Comment

Popular posts from this blog

Image
 Diagnosis DIMORPHIC ANAEMIA(BICYTOPENIA) WITH CKD(STAGE 4) WITH 4 SESSIONS OF HEMODIALYSIS DONE(2019) Case History and Clinical Findings COMPLAINTS: 80 YEAR MALE WITH C/O TINGLING AND NUMBNESS OF BOTH UL AND LL SINCE 1 WEEK. HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC TILL LAST WEEK,THEN DEVELOPED HAEMATURIA SINCE LAST FRIDAY, IN EACH EPISODE OF URINE OUTPUT, WHICH LASTED FOR 4 DAYS.NO AGGREVATING FACTORS, NO RELIEVING FACTORS. H/O DECREASED URINE OUTPUT SINCE 1 MONTH, BUT INCREASED FREQUENCY. NO H/O BURNING MICTURITION, HESITANCY OR URGENCY NO H/O BLEEDING MANIFESTATIONS,PETECHIAE,RASH,NO HEMATURIA,NO BLOOD IN STOOL(MELENA),NO BLLEDING GUMS. NO H/O FEVER, COUGH, COLD, PAIN ABDOMEN NO H/O CHEST PAIN, PALPITATIONS, ORTHOPNEA AND PND TINGLING AND NUMBNESS OF UL AND LL SINCE 1 WEEK. NO POLYPHAGIA,POLYDYPSIA,NOCTURIA POLYURIA PRESENT UROLOGY REFERRAL TAKEN IN VIEW OF HEMATURIA ?URINARY BLADDER CARCINOMA DIAGNOSIS:BPH WITH GRADE 2 RPD CHANGES ADVICE:T.TAMSULOSIN 0.4 MGX2 WEEKS T.PANTOP 40MG
Read more

A 21 yr old female with pyrexia and vomitings

Image
  July 26, 2022 Medical case disscussion  July 23,2022 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 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 inthe comment box are welcome. Name : Jyothi Reddy  Roll no : 44 I have been given this case to solve an attempt to understand the topic of "patient clinical analysis data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan          CASE DISCUSSION A 21 year old female patient from Islamilpalli , who's a Bsc nursing st
Read more