55year old male with c/o fever, cough and loose stools

 DR. YAMINI ( INTERN)

DR. AMULYA ( INTERN) 

DR. SURYA PRADEEP ( INTERN)

DR. ASHA KIRAN ( INTERN)

DR. JAYANTH ( INTERN) 

DR. VAMSHI ( INTERN)

DR. ISMAIL ( INTERN ) 

DR. PRADEEP ( PG 1st YEAR)

DR. NIKITHA (PG 2nd YEAR)

DR. SUFIYA ( PG 3rd YEAR) 

DR. SATISH ( PG 3rd YEAR)

Faculty : DR. VIJAYALAXMI

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 individual 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 on the comment box is welcome. Here is a case i have seen: 

55 YEARS OLD  MALE  DAILY WAGE LABOURER   CAME WITH COMPLAINTS  OF FEVER  AND COUGH ( since  20 days ) , LOOSE  STOOLS  2 DAYS  AGO  ,

PATIENT WAS APPARENTLY ASYMPTOMATIC  2O DAYS  BACK THEN HE  HAS  INSIDIOUS  ONSET  OF FEVER  , LOW GRADE  , CONTINUOUS  , NOT ASSOCIATED WITH  HEADACHE  , VOMITING,  BURNING MICTURITON  , EAR PAIN , EAR  DISCHARGE  ,FEVER IS ASSOCIATED  WITH  COUGH  AND EXPECTORATION , WHITISH  IN COLOUR  , SMALL QUANTITIY , COUGH IS CONTINUOUS  THROUGHOUT  THE DAY , NOT ASSOCIATED  WITH  WEIGHT  LOSS , NIGHT  SWEATS  ,COUGH IS ASSOCIATED WITH  CHEST DISCOMFORT  AND ABDOMINAL DISTENSION  ,PATIENT  HAD LOOSE STOOLS  5 EPISODES  / DAY  FOR 2 DAYS  , WATERY IN CONSISTENCY, N0T ASSOCIATED  WITH PAIN ABDOMEN  , AND BLOOD IN STOOLS 

K/C/O  DM 2  ( 20 YEARS ON MEDICATION  ) 

NOT A K/C/O  HTN / TB  /EPILEPSY  / CVA / CAD 

PERSONAL  HISTORY  

DIET MIXED 

APPETITE   NORMAL  

REGULAR   BOWEL AND   BLADDER   MOVEMENTS  

CHRONIC  ALCOHOLIC  FOR 20 YEARS TAKES  90 ML / DAY  STOPPED 3 MONTHS BACK  

ON EXAMINATION  

TEMP - AFEBRILE  

BP - 1OO/70 MMHG 

PR - 79 BPM 

SpO2 - 94 % 

GRBS  - 271 MG % 

PT IS CONSCIOUS  , COHERENT  , COPPERATIVE ,  ORIENTED TO TIME  PLACE  AND PERSON ,  

NO SIGNS  OF  PALLOR  , ICTERUS,  CLUBBING , CYANOSIS,  GENERALIZED  LYMPHADENOPATHY  ,PEDAL EDEMA  . 

CVS  - S1 S2 HEARD 

RESP  SYSTEM  - B/L AIR  ENTRY  PERESNT , NO ADDED  SOUNDS 

CNS -  HEIGHER  MENTAL  FUNCTIONS  ARE  NORMAL  

 CRANIAL NERVES  INTACT

NECK  STIFFNESS  ABSENT 

MOTOR  SYSTEM  -  

TONE  -  B/ L UPPER  LIMBS , LOWER  LIMBS  NORMAL  .

REFLEXES  

BICEPS    ++

TRICEPS  ++

SUPINATOR  ++

KNEE ++

ANKLE  ++

CEREBELLAR  SIGNS  - ABSENT

PROVISIONAL DIAGNOSIS: 

FEVER ? SECONDARY TO PNEUMONIA 

INVESTIGATIONS: 

CHEST- XRAY

 

FBS- 116mg/dl 

TREATMENT: 

1 INJ  PAN 40 MG IV × OD 

2 INJ  AGUMENTIN 1.2 GM × IV × TID   ( I- I -I ) 

3 TAB PCM  500mg × po× TID 

4 IVF 1 UNIT NS @ 75 ML / HOUR