A 45 year old female with acute gastroenteritis
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
Chief complaints:
A 45 year old female came to casuality with chief complaints of :
fever since 4 days ,
vomitings since 4 days ,
pain abdomen since 4 days
HOPI:
Patient was apparently asymptomatic 3 years back ,then she had pain in both her knees and she observed swelling in both her lower limbs ,initially the pain reduced on taking medications.
1 month 1week back she had right tibial fracture (cause of fracture: slipped from staircase) at around 2 pm in the noon
On the day of fall: initially patient didn’t complain of any pain or swelling in the legs , but patient heard a sound at the time of fall and she was unable to walk .
Following which she observed edema in her right leg which is apparently more when compared to the edema she had earlier.
patient went to local rmp on the same day,X-ray was taken and they were informed about the fracture and the need for the surgery .
Later on the same day of fall they consulted another private hospital and the surgery was planned.Two days after the fall pt underwent surgery for Right sided fracture of tibia and advised to take complete bed rest for 2months .
On the day of surgery:she had severe pain and swelling in the operated leg (right ) ,the pain subsided after taking medication.
Next day after surgery: she was discharged .
Follow up : Weekly once for two weeks after surgery .
Since 4 days she’s having fever which is low grade and associated with chills,
Patient had vomitings since 4 days -she had 5-6 episodes per day which is non bilious,non projectile,food as content
Patient also complaints of abdominal pain since 4 days ,pain is diffused all over the abdomen .
Patient has SOB intermittently since one month .
Past history:
She is a known case of DM since 2 months on metformin(500 mg)
Not a known case of HTN,TB,Epilepsy
Personal History:
Diet:mixed
Appetite: decreased
Sleep: adequate
Bowel and bladder movements: regular
Addictions:none
General examination:
Patient is conscious,coherent and cooperative and well oriented to time place and person.
No pallor,icterus,cyanosis,clubbing
Bilateral pedal edema
White patches are seen over the tongue
Vitals :
Temperature: afebrile
BP: 100/80
PR: 74 bpm
RR:16 cycles per min
CVS :
S1, S2 heard , No murmurs
RS :
Position of trachea: central
Normal vesicular breath sounds heard
PER ABDOMEN:
Abdomen is soft and there is mild diffuse tenderness
Bowel sounds heard.
CNS:
Patient is Conscious ,oriented to time,place and person
HMF -intact
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
No meningeal signs
Investigations:
Hemogram:
CUE:
Serum creatinine:1.9 mg/dL
Blood urea:52 mg/dL
Serum electrolytes :
Na-135 mEq/L
K-3.8 mEq/L
Cl-99 mEq/L
LFT:
Total bilirubin -5.46
Direct bilirubin -2.09
SGOT-23 IU/L
SGPT-15 IU/L
Alkaline phosphate-229
Total proteins-42
Albumin-2.3
LDH: 224
Reticulocyte count:0.7
ESR: 80
HbA1c:6.5
Ultra sound report:
Colour Doppler 2D echo:
Orthopedic referral:
X-Ray:
Clinical images :
Right and left lower limbs:
Abdomen of patient:( in anteroposterior and lateral views)
Diagnosis:
Acute gastroenteritis with DM-II
Candidiasis(?)
Infected right ILMN tibia with loosening of implant.
Treatment:
IV NS -100 mL/hr
Inj.Pantop-40mg IV/OD
Tab.PCM-650 mg PO/SOS
Inj.Zofer 4mg IV/TID
Inj.HAI according to sliding scale
Tab.Fluconazole 150 mg PO/OD
Candid mouth paste
Tab.Orofer -XT PO/BD
Physiotherapy
Inj.Monocef 1gm IV/BD
Inj.Clexane 40 mg S/C OD
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