69 year old female with fever since 10 days

This is an online e log book to discuss patients de identified data after taking his or her signature in informed consent form . Here we discuss our individual patient problems through series of input from available global online community of experts with an aim to solve patient clinical Problems with collective current best evidence based inputs. Thia e log book also reflects my patient centered online portfolio and your valuable inputs in comments. 


A 59 year old patient came to opd with fever since 10 days 
History of present illness 
Patient was asymptomatic 10 days back later developed fever with evening rise of temperaturenot assciated with chills, rigors relieved on medication.  Genralized weakness, loss of weight , no chest pain, chest tightness, haemoptysis, wheeze, palpitations , brrathlesness. 3 episodes of vomitings for 5  days used medication and resolved. Loose stools 1 episode resolved on medication. 
History of past illness
History of carcinoma cervix 13 years back undervent radiation therapy (24 sessions). HTN since one month. Tab. Metoprolol 50mg od, tab. Citridipine 10mg od., no history of asthma, DM, epilepsy, CAD, Tb. 
Personal history 

Married, housewife 
Normal appetite
Diet - non veg 
Bowel - regular
Micturation - normal 
No known allergies 
No known family history 

Systemic examination
Cvs 
No thrills, cardiac murmurs 
Cardiac sounds s1s2 + 
Respiratory system 
No wheeze, dyspnoea. 

Inspection 
Shape of chest - elliptical 
Expansion of chest decreased on left,  no drooping of shoulders, supra and infra clavicular hollowness  , Crowding of ribs ,  wasting of muscles , suprascapular distance reduced, apical impulse not seen. 

Palpation 
All inspectory findings are confirmed 
No tenderness 
Trachea deviated to left side 
No local rise of temperature 
Chest movements decreased on left side 

Percussion 
Direct resonate 
Abdomen 
Shape - scaphoid 
No  tenderness, palpable mass, bruits, free fluid. 
Liver, spleen not palpable 
Hernial orifice normal 
CNS
Patient is conscious ,speech is normal 
No kernings sign, neck stiffness. 
Investigation 
CBP, CXR PAPA view, RFT, LFT. 
Diagnosis 
Malignant mass on left side 
Treatment
Inj. Ceftriaxone 1 mg iv bd 
Pan 40mg iv od
Tab. Dolo 650mg bd 
Tab. Mvt po od 
Tab. Metoprolol  50mg po od 
Tab. Citridipine 10mg po od 







Popular posts from this blog

60 year old female with epidermoid cyst

Image
This is an onlin E log book to discuss our patients de-identified health data shared after taking his/her/guardian signed informed consent . Here we discuss Our individual patients problems through Series of inputs From available global online Community of experts with an aim to solve those patients 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 comments .   A 60 year old female came with the chief complaint of mass over perianal region since 6 months History of present illness  Patient was apparently asymptomatic 6 months back then she developed the small swelling of size 1×2 cm of insidious onset and slowly proffused to present size of 3×3 cm not associated with pain fever and vomiting constipation burning sensation  History of past illness No history of similar complaints either pain  No know history of hypertension , DM , asthm...
Read more

36 year old male with uncontrolled sugar,left lower rib fracture , ulcer in left toe

Image
This is an online E log book to discuss Our patients de-identified health data shared after taking his/her/guardian signed informed consent . Here we discuss Our individual patients problems through Series of inputs From available global online Community of experts with an aim to solve those patients 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  A 36 year old male was admitted i/v/o left lower rib pain , uncontrolled sugar , Ulcer in left  toe  History of presenting illness  Patient was apparently asymptomatic 7 years ago .when he had an episode of giddiness and fallen he went to an hospital . Where he was diagnosed with diabetes mellitus .He started with OHAs he used to get his regular checkup done and FBS and PLBS were under control with metformin. He later shifted to GLIMI M1 and GLIMI MV2 2-3 months back .  3 years ago...
Read more