Skip to main content

2Yr old female, with fever and vomitingJanuary 11, 2022

2Yr old female, with fever and vomiting
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-centred online learning portfolio and your valuable comments on comment box are welcome. 

NAME: Ankitha
Roll no: 67
Batch: 2017
 
Case history:

 A 42 y /F came to the casualty with complaints of fever , nausea , vomitings, constipation , generalised weakness since 7days ; burning micturition since 1day 

HOPI- 

 Patient was apparently asymptomatic 1week back when she developed fever, which is intermittent, not associated with chills , rigors , associated with generalised weakness. Its also associated with nausea , constipation , passing flatus.

 Patient also complaints of nausea associated with one spontaneous episode of vomiting. Following which the patient stimulated vomiting by herself whenever she feels nauseating.

 No c/o loose stools.
 C/o burning micturition since 1day . 
 Dry cough since 1day No c/o sputum , SOB , bleeding manifestations. 

Not a k/c/o DM , HTN ,TB, Asthma , CAD 

Personal history - 
Diet - mixed 
Appetite - Decreased 
 Sleep - Adequate 
 Bowel and bladder movements-- constipation Rashes and itching on eating non veg . 
No addictions . 

Family history - not significant. 

On Examination - 

 GENERAL EXAMINATION 

Patient is conscious Oriented Co-operative Moderately built Well nourished 
Palor - absent 
 Icterus absent 
Cyanosis – absent 
Clubbing – absent 
Pedal edema – absent 
No lymphadenopathy 

 VITALS: 
PULSE: rate : 100bpm, regular rhythm, normal volume, and character, felt in all peripheral pulses, no radioradial delay, condition of vessel wall normal. 
 BLOOD PRESSURE: 110/70mm of Hg measured in the left Upper limb with the patient in supine position 
RESPIRATORY RATE: 26/min, type-thoracoabdominal. 
 TEMPERATURE: 98°F measured in the Axilla 


SYSTEMIC EXAMINATION: 

ABDOMINAL EXAMINATION:  

INSPECTION: 
Shape – Generalized fullness due to fat Umbilicus – Position: central, Shape- inverted Skin – normal with no scars, or sinuses, no dilated veins 
Abdominal wall moves with respiration, no visible gastric peristalsis,no visible intestinal peristalsis 

 PALPATION: 
No tenderness or superficial raise in temperature. On deep palpation, no significant organomegaly 

Measurements - Abdominal Girth: 90cms, Distance between the Xiphisternum-Umbilicus is 18cms and Umbilicus-Pubic Symphysis is 22cms 
No renal angle tenderness 


 PERCUSSION: 
Liver span: 12cms


AUSCULTATION: 

Bowel sounds – audible in right iliac fossa Bruit – Absent 



 CNS EXAMINATION: 

Higher mental functions intact 

Cranial nerve examination normal 

Motor examination: Bulk: normal in all muscles                                       Tone: normal in all muscles                                     Power 5/5 in all muscles 

Reflexes: superficial and deep reflexes present 

Sensory system: Pain, temperature, touch, vibration sensations are present, Two point discrimination, tactile localisation present 

Cerebellar functions normal 



 RESPIRATORY SYSTEM: 

 INSPECTION: 

 Upper respiratory tract: no significant findings 

Lower respiratory tract: 

Position of trachea is midline 
Chest symmetrical 
Movement of chest: equal on both sides with respiration 
No visible dilation of veins no scars ,sinuses 


PALPATION: 

Trachea is in midline 
Chest expansion: Normal and equal on botgh sides  
Vocal fremitus: equal on both sides 

PERCUSSION:.  Right Left 

Clavicular percussion.    resonant on both sides Kronig’s isthumus.           resonant on both sides Infraclavicular.                 resonant on both sides Mammary.                        resonant on both sides Axillary.                             resonant on both sides 
Infraaxillary.                     resonant on both sides Suprascapular.                resonant on both sides Infrascapular.                  resonant on both sides Upper/mid/lower 
 interscapular region.     resonant on both sides 


AUSCULTATION: 

Breath sounds: Normal Vesicular Breath sounds heard in all auscultatory areas. 
 No added breathe sounds  

Vocal resonance: 
Clavicular percussion    resonant on both sides Kronig’s isthumus.         resonant on both sides Infraclavicular.                resonant on both sides Mammary.                       resonant on both sides Axillary.                            resonant on both sides Infraaxillary.                    resonant on both sides Suprascapular.                resonant on both sides Infrascapular.                  resonant on both sides Upper/mid/lower
 interscapular region.     resonant on both sides 


CARDIOVASCULAR EXAMINATION: 

JUGULAR VENOUS PULSE: 

INSPECTION: Chest wall elliptical in shape and symmetrical, 
Precordial bulge absent 
 Dilated veins, scars, sinuses absent 
Apical impulse not seen 
Pulsations – no visible pulsations 


PALPATIONN:

 Apical impulse – normal in left 5th ics , 1cm medial to midclavicular line. 
 No parasternal Heave or thrills 


PERCUSSION: 


 AUSCULTATION: S1 S2 heart sounds are heard No abnormal heart sounds heard. 

CLINICAL IMAGES:




X-ray:








Fever chart:



INVESTIGATIONS:
 


Provisional diagnosis -Fever under evaluation 
                                        UTI ?


Treatment - 

IVF -NS,RL,DNS @75ML)HR 
INJ PANTOP 40MG IV OD
INJ ZOFER 4MG IV SOS 
INJ OPTINEURON 1AMP IN 100ML NS IV OD INJ NEOMOL 1GM IV SOS (IF TEMP >101°F) TAB DOLO 650 MG PO SOS 
SYP LACTULOSE 10ML 

Comments

Post a Comment

Popular posts from this blog

A69 YR OLD MALE WITH BILATERAL HYDROURETERO NEPHROSIS AND AKI ON CKD

Image
  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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT . Name : Ankitha reddy Roll no : 67 CASE :  A 69 year old male who is farmer by occupation came to the opd with cheif complaints of : B/L pedal edema present since 15 days Burning micturation since 15days Increased frequency of micturition (10-15times per day ) and urgency  Nocturia 5-6 times  Itching all over the body since 7 days HISTORY OF PRESENTING ILLNESS:  Patient was apparently asymptomatic 15 days back and later he developed bilateral pedal which is pitting type of edema since 15 days and buring micturition . There is increased frequency of urination i.e; 10 to 15times per day and nocturia...
Read more

32 yr old male with fever and generalized weakness

Image
MEDICAL ONLINE BLENDED BIMONTHLY ASSIGNMENT(MAY-2021)  32 yr old male with fever and generalized weakness    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 NAME : Ankitha Reddy ROLL NO : 67 A 32yr old male who is a farmer by occupation was brought to casualty with  CHEIF COMPLAINTS :  FEVER since 1 week. HEADACHE since  5 days GENERALISED WEAKNESS AND JOINT PAINS HISTORY OF PRESENT ILLNESS:  Patient was apparently asymptomatic 1 week back. Then he developed fever which is moderate to high grade, intermittent ( o...
Read more

Internship Assessment

Name : Ankitha Roll no : 78 2017 Batch Period of Posting : 12/02/23 to 13/04/23 This blog is all about my learning experiences  in 2 months of my internship while i was posted in general medicine department. First i had Psychiatry posting for 15 days  During Psychiatry  postings : 1. I got to see numerous cases in the opd which includes schizophrenia , depression, alcohol dependence disorder , drug addiction , postpartum blues , anxiety , panic attacks . 2. I learnt to take history of such diverse cases and understood the importance of patient confiding in us and how it impacts our diagnosis and treatment. 3. I learnt to manage and monitored patients in delirium  4. I visited de-addiction centre and learned about the activities done there and treatment given for those patients. 5. I learnt to do mental status examination  Then i was posted in UNIT-6 in medicine department for 1month  OP AND UNIT duty experience: We had op days every Saturday and saw approxi...
Read more