NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.
A 37 YR OLD MALE, LORRY DRIVER BY OCCUPATION, RESIDENT OF CHITYALA COMPLAINING OF FEVER SINCE 10 DAYS AND PAIN IN THE EPIGASTRIUM SINCE 2 HRS
PT WAS APPARENTLY ASYMPTOMATIC UNTIL 10 DAYS BACK AND THEN HAD FEVER WITH CHILLS AND RIGORS, SUDDEN ONSET, INTERMITTENT FEVER, AGGREVATED AT NIGHTS, AND RELIEVED AFTER TAKING DOLO, ACCOMPANIED BY WHITE ORAL MUCOSAL PATCH, BODY PAINS, SOB
PT COMPLAINS OF EPIGASTRIC PAIN WITH BURNING SENSATION SINCE 2 HRS, SUDDEN ONSET, NON RADIATING
NO C/O COUGH, CHEST PAIN, COLD, GIDDINESS, HEADACHE, BURNING MICTURATION, LOOSE STOOLS, NAUSEA, VOMITINGS
K/C/O DM TYPE II SINCE 5 YRS ON METFORMIN HYDROCHLORIDE 500MG AND GLIMIPERIDE 2G AND VOGLIBOSE 0.2 TABLETS 1 TAB IN THE MORNING AND HALF AT NIGHT
PERSONAL HISTORY:
APPETITE NORMAL
DIET MIXED
BOWEL AND BLADDER MOVEMENTS NORMAL
SLEEP ADEQUATE
PT WAS APPARENTLY ASYMPTOMATIC UNTIL 10 DAYS BACK AND THEN HAD FEVER WITH CHILLS AND RIGORS, SUDDEN ONSET, INTERMITTENT FEVER, AGGREVATED AT NIGHTS, AND RELIEVED AFTER TAKING DOLO, ACCOMPANIED BY WHITE ORAL MUCOSAL PATCH, BODY PAINS, SOB
PT COMPLAINS OF EPIGASTRIC PAIN WITH BURNING SENSATION SINCE 2 HRS, SUDDEN ONSET, NON RADIATING
NO C/O COUGH, CHEST PAIN, COLD, GIDDINESS, HEADACHE, BURNING MICTURATION, LOOSE STOOLS, NAUSEA, VOMITINGS
K/C/O DM TYPE II SINCE 5 YRS ON METFORMIN HYDROCHLORIDE 500MG AND GLIMIPERIDE 2G AND VOGLIBOSE 0.2 TABLETS 1 TAB IN THE MORNING AND HALF AT NIGHT
PERSONAL HISTORY:
APPETITE NORMAL
DIET MIXED
BOWEL AND BLADDER MOVEMENTS NORMAL
SLEEP ADEQUATE
CONSUMES ALCOHOL EVERYDAY AFTER HECTIC LORRY DRIVING (2 PEGS)
FAMILY HISTORY: INSIGNIFICANT
GENERAL EXAMINATION:
NO PALOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA
HYPOPIGMENTED PATCH ON ABDOMEN
WHITE ORAL MUCOSAL PLAQUES
VITALS:
TEMP: 102F
PR: 113 BPM
BP: 110/70 MMHG
SPO2: 99% AT RA
GRBS: 66 MG/DL
SYSTEMIC EXAMINATION:
CVS: S1,S2 HEAR
RS: BAE PRESENT
P/A: SOFT, NON-TENDER
CNS: NAD ( E4V5M6 )
FAMILY HISTORY: INSIGNIFICANT
GENERAL EXAMINATION:
NO PALOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA
HYPOPIGMENTED PATCH ON ABDOMEN
WHITE ORAL MUCOSAL PLAQUES
VITALS:
TEMP: 102F
PR: 113 BPM
BP: 110/70 MMHG
SPO2: 99% AT RA
GRBS: 66 MG/DL
SYSTEMIC EXAMINATION:
CVS: S1,S2 HEAR
RS: BAE PRESENT
P/A: SOFT, NON-TENDER
CNS: NAD ( E4V5M6 )
INVESTIGATIONS:
Amylase: 27
Lipase: 15
DIAGNOSIS:
PYREXIA 2⁰ TO CYSTITIS
UNCONTROLLED SUGARS
WITH TYPE II DM SINCE 5 YRS
TENIA CORPORIS ET CRURIS ? HERPES LABIALIS WITH RVD POSITIVE
TREATMENT:
1.IV FLUIDS AT 75ML PER HR
2. INJ PIPTAZ 4.5 G IV TID
3.INJ HAI S/C ACC TO GRBS
4.INJ PAN 40MG IV BBF
5.ORAL MUCAINE GEL FOR L/A
6.T HIFENAC P BD FOR 3 DAYS
7.LULIFIN CREAM L/A
8. T RIBOFLAVIN 10MG PO BD
9.VITALS MONITORING
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