A 60y old female pt came with c/o fever ,vomiting and headache since 4 days

 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. 

CASE PRESENTATION:

A 60y old female patient came to opd with c/o 

1.fever since 4 days 

2.C/o headache since 4 days

3.vomitings since 4 days

Patient was apparently asyptomatic 4 days back , 

later she had fever which was insidious in onset,progressive,low grade and  not a/w chills,intermittent type with no diurnal variations,no aggregating or relieving factors

C/o headache since 4 days ,diffuse type not a/w diplopia,blurring of vision.No h/o any head trauma

C/o body pains since 4 days (generalized)

C/o vomiting since 4 days 2-3 episodes of vomitings with contents of food particles,non foul smelling,non bilious,non projectile .No h/o pain abdomen

H/o loose stools since 1 day (1 episode).non blood stained

No h/o cold ,cough,headache,burning micturition,haematuria,sob,chest pain,pedal edema

PAST HISTORY: k/c/o Thyroid since 8 years (on tab.carbimazole 10mg)

Not k/c/o DM,HTN,asthma,CKD,CHD

Non alcoholic and non smoker.No other addictions 

HABITS: He was on mixed diet, appetite normal, constipation only on high protein diet 

GENERAL EXAMINATION: pt is conscious, coherent, cooperative and oriented to time, place and person

No pallor,Icterus,cyanosis,clubbing, lymphadenopathy,edema


VITALS:

Temp:99.1f on presentation 

BP:70/40mmhg on presentation 

PULSE:79pm

RR:21cpm

Spo2:98% on RA

GRBS:124mg/dl

PER ABDOMEN:

Soft,non tender

Bowel sounds +


CVS:s1 s2 heard, no murmurs

RS: BAE clear, normal vesicular breath sounds heard,no added sounds


CNS: higher mental functions: normal

        Cranial nerves: intact

       Motor system: intact

       Sensory system: intact

INVESTIGATIONS:






PROVISIONAL DIAGNOSIS: ? ACUTE GASTROENTERITIS WITH AKI WITH ANEMIA AND THROMBOCYTOPENIA K/C/O HYPERTHYROID.

Treatment:
1.IVF(NS,RL)@50ML/HR CONTINUOUS
2.INJ.PANTOP 40MG/IV/OD                   
3.INJ.ZOFER 4MG/IV/BD                        
4.T.PCM500MG/TID/pO
5.INJ.CIPROFLOXACIN 400mg/IV/BD              
6.INJ.METROGYL 500MG/IV/BD                       7.TAB.OROFER xT /PO/BD                                
8.I/O CHARTING AND MONITORING VITALS


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