LONG CASE:
CHIEF COMPLAINTS:
A 55 yr old female who is house maid by occupation came to the hospital with chief complaints-
Fever since 5 days
Neck stiffness since 5 days
History of present illness:-
- Patient was apparently asymptomatic 5 days back then she had fever which is sudden in onset and continuous type and relieved on medication and associated with tremors.
Complaints of bilateral knee joint pains .
Negative history:-
Fever not associated with chills and rigors. No h/o cold ,cough ,loose stools , abdominal pain , breathlessness, PND , orthopnoea. No history of burning micturition, increased frequency of micturition.
- There is h/o headache from 25 days but it got aggravated since 5 days which is insidious in onset and progressive for which she took medication but not relieved. No aggravating and relieving factors . - History of neck stiffness since 5 days.
- History of vomiting 3 days back ,1 episode which is not projectile ,non bilious ,content is food particles .
PAST HISTORY:-
No history of similar complaints in the past.
Medical illness - Not a known case of diabetes , hypertension, asthma, TB, Thyroid .
•7 yrs back she had history of CVA where both upper and lower limbs are paralysed and took some medication.
she took allopathy medicine 6 months back and she got recovered.
•Surgical history- hysterectomy done 25 yrs back .
FAMILY HISTORY:-
No similar complaints inthe family
No history of diabetes, hypertension,TB ,asthma.
PERSONAL HISTORY:-
Diet - mixed
Appetite - lost
Sleep - adequate
Bowel and bladder- regular bladder and constipation is present .
No addictions and allergies.
GENERAL EXAMINATION:-
Patient is conscious, coherent, coperative. Moderately built moderately nourished.
No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, generalised edema.
VITALS:
Temperature: 99°F
Pulse rate: 78bpm
Resp rate:15cpm
BP:110/70mmhg
Spo2:98%
SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM::-
Higher mental functions
• conscious
• oriented to person and place ,time.
• memory - able to recognize their family members
• Speech - normal
CRANIAL NERVES examination -
• 1 - sense of smell present
• 2- Direct and indirect light reflex present
• 3,4,6 - no ptosis Or nystagmus
• 5- corneal reflex present on both sides
• 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present.
• 8- able to hear
• 9,10- uvula not deviated
• 11- sternocleidomastoid contraction present
• 12- no tongue deviation
Motor system
Tone -. Upper limbs
Tone: Lower limbs
Inspection - Normal Normal
Palpation - Normal Normal
Bulk : right Left
Arm :- 28cm. 27cm
Forearm:- 20cm 18 cm
Thigh: 33 cm 32cm
Calf:. 25 cm 23 cm
Power :
Muscles of neck -
• stenocleidomastoid- good
•Nuchal muscles- stiffness present
Slight tenderness present over the neck on examination.
Right Left
Biceps- 5/5 5/5
Triceps-. 5/5 5/5
Brachioradialis-. 5/5 5/5
Tibialis posterior-. 5/5 5/5
Reflexes: right left
Biceps- + +
Triceps- + +
Ankle - + +
Sensory system: Normal
Cerebellar signs :
Knee - heel incoordination - No
Finger - nose incoordination- No
Meningeal signs -
Neck stiffness present .
Kernig's sign - positive
Brudzinki sign - positive
EXAMINATION OF OTHER SYSTEMS
CARDIOVASCULAR SYSTEM:
S1 S2 Heart sounds – normal
No thrills/murmurs
RESPIRATORY SYSTEM:
Chest symmetrical, No paradoxical movements, Normal vesicular breath sounds heard,
No abnormal/added sound
ABDOMEN:
Abdomen is soft, non tender,No organomegaly, No ascites.
Provisional diagnosis:VIRAL FEVER with VIRAL MENINGOENCEPHALITIS under evaluation and detected denovo DIABETES MELLITUS type 2.
Investigations:-
GRBS - 100 mg/dl
Hb - 13 g/dl
TLC - 3500
N/L/E/M-60/30/2/8
PLT- 2.1 lakh per mm3
FBS- 168**mg/ dl
Hb1 AC -6.9*
Urea- 38
Serum creatinine- 1.0
Uric acid - 4.9
Sodium- 141meq
Pottasium- 4.0
chloride- 1058
Serology
LFT:
Tb - 1.03
Db- 0.31
SGOT(AST) - 69
SGPT(ALT) - 68
ALP-135
Tp-6.4
Albumin-4.0
CUE:
Albumin +
Sugar - nil
Pus cells - 6 - 8
Epithelial cells- 3-4
RBC - nil
Casts - nil
CSF :
Sugar - 81
Protein-12.6
Chloride-113
ABG:
pH - 7.4
Pco2- 29.1
Po2- 88.4
Hco3- 18.0
Sat O2 - 97%
X Ray - knee joint AP view
X ray Lateral view of skull and neck-
ECG
Treatment:-
Inj. CEFTRIAXONE 2 gm/ BD
Inj.DEXA 6mg/iv/tid
Inj . Vancomycin 1gm/iv
Inj. Pcm 1gm/iv
Tab . Pcm 650 mg
Tab. Ecospirin 75 mg /po/od
Tab. Atorvas 10 mg /po/od
Syp. Cremaffin plus 30ml/po
On day 2 :-
Patient is conscious, coherent, cooperative.
Vitals:-
Temperature: 99°F
Pulse rate: 76bpm
Resp rate:15cpm
BP:130/90mmhg
Spo2:96%
GRBS- 197mg/dl
Treatment-
Inj. CEFTRIAXONE 2 gm/ BD
Inj.DEXA 6mg/iv/tid
Inj . Vancomycin 1gm/iv
Inj. Pcm 1gm/iv
Tab . Pcm 650 mg
Tab. Ecospirin 75 mg /po/od
Tab. Atorvas 10 mg /po/od
Syp. Cremaffin plus 30ml/po
Oint.Diclofenac for thigh pain
On day 3:-
Patient is conscious, coherent, cooperative.
Vitals:-
Temperature: 99°F
Pulse rate: 78bpm
Resp rate:16cpm
BP:120/90mmhg
Spo2:96%
GRBS- 190mg/dl
Investigations:-
Treatment-
Inj. CEFTRIAXONE 2 gm/ BD
Inj.DEXA 6mg/iv/tid
Inj . Vancomycin 1gm/iv
Inj. Pcm 1gm/iv
Tab . Pcm 650 mg
Tab. Ecospirin 75 mg /po/od
Tab. Atorvas 10 mg /po/od
Syp. Cremaffin plus 30ml/po
Oint.Diclofenac for thigh pain
Inj.pan 40 mg iv /od
Tab. Naproxen 250 mg po/tid.
Flexbenz gel for L/A on thighs
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SHORT CASE:
25year old female wit 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:
History of presenting illness:
No H/O chest pain palpitations shortness of breath
No H/O of pedal edema
NoH/O decreased urinary output
No H/O seizures
No H/O headache blurring of vision
Past history:
Diagnosed with hypertension during first pregnancy: intrauterine death at 6th month
She had hyperemesis during first pregnancy in the first trimester
Second pregnancy: baby delivered at 8 th month normal vaginal delivery and died with in one day
Not a known case of diabetes Mellitus, TB, asthma, thyroid disorders , epilepsy
No past surgical history
No blood transfusions done
Menstrual history:
Age of menarche: 13 years
28 day cycle regular bleeds for 3 days
Associated with back ache
Not associated with clots
Marital history:
Married in 2020 non consanguineous
Personal history:
Occupation : house wife
Diet mixed
Appetite normal
Sleep adequate
Bowel and bladder: regular
No addictions
Family history:
Not significant
General examination:
Patient is conscious coherent and cooperative
well oriented to time place and person moderately built and nourished.
Height :161cm
weight:58kg
BMI:22.3kg/m2
No pallor
icterus
cyanosis
clubbing
generalised lymphadenopathy
edema
Vitals :-
pulse rate:90bpm
BP:170/100 mmHg
Respiratory rate:22cpm
Temperature: afebrile
SpO2: 98%
GRBS 164 mg%
Systemic examination:
CVS
Auscultation:S1 S2 sounds heard
no murmurs and
no added sounds
Abdominal examination:
Inspection
Shape scaphoid
Umbilicus inverted
No visible gastric peristalsis
Hernial orifices free
Palpation
soft ,non tender ,no organomegaly
Bowel sounds heard on auscultation
Respiratory system :
Inspection
trachea central in position
Chest movements symmetrical
Auscultation:
BLAE present
NVBS heard
Investigations:
Provisional diagnosis:Young onset hypertension
Treatment:
1)Tab.AMLONG 5mg PO/OD
2)Tab.ZINCOVIT PO/OD
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