53YEAR OLD MALE FEVER SINCE 2 MONTHS , VOMITINGS SINCE 10 DAYS

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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:

COMPLAINTS OF FEVER SINCE 2 MONTHS 

C/O VOMITINGS SINCE 10 DAYS 

HISTORY OF PRESENT ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS AGO THEN DEVELOPED FEVER , INSIDIOUS ONSET ,LOW GRADE ON AND OFF ,RELIEVED WITH MEDICATION THEN SINCE 10 DAYS FEVER HIGH GRADE A/W CHILLS AND RIGOR ,MORE IN EVENING TIMES , RELIEVED WITH MEDICATION 

C/O VOMITINGS, INSIDIOUS ONSET, MULTIPLE EPISODES /DAY SINCE 10 DAYS GREENISH COLOR THEN FOOD AS CONTENTS 

H/O PAIN ABDOMEN INSIDIOUS ONSET,DIFFUSE ,SPASMODIC 

H/O MALENA SINCE 10 DAYS 

H/O SOB SINCE 7 DAYS GRADE 4 MMRC 

H/0 WEIGHT LOSS ,LOSS OF APPETITE 

H/O COUGH WITH SPUTUM 

H/O PEDAL EDEMA 

H/O MULTIPLE JOINT PAINS SINCE 10 DAY

PAST HISTORY:

K/C/O CHRONIC PANCREATITIS SINCE 7 YEARS 

K/C/O DM2 SINCE 2 YEARS ON T.GLIMI M1 PO/OD

N/K/C/O HTN,CVA,CAD,THYROID ,TB,ASTHMA 

PERSONAL HISTORY:

Diet- mixed (with non-veg predominant)

Sleep-adequate

Appetite- normal 

Bowel and bladder- Regular 

Addictions- 

Alcoholic since 30years 

Smoking 21 cigarettes /day

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative,moderately built and nourished

Pallor-absent 

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

VITALS :

Temperature- afebrile 

Pulse rate- 108bpm

RR- 26cpm

Blood pressure-100/60 mmhg

Grbs:- 219mg/dl

SpO2:- 98% @room air

SYSTEMIC EXAMINATION:

CVS :

S1S2 Heard 

No murmurs 

Resp :

NVBS +

B/l air entry+

CNS:

The patient is conscious. 

No focal deformities. 

cranial nerves - intact 

sensory system - intact

motor system - intact

PER ABDOMEN:

 Soft non tender

Bowel sounds heard.

CHEST X RAY:

ECG :

CECT ABDOMEN:

2D echo:

USG ABDOMEN & PELVIS:

Hemogram:

CUE-

LFT 

RFT

LIPID PROFILE 

SERUM ELECTROLYTES 

LIPASE 

AMYLASE 

FBS 

HbA1c

BLOOD UREA 

Serum CREATININE 

SPOT UPCR

24HRS UPCR

Bleeding time & CLOTTING TIME 

APTT

PT&INR 

TROP I

ESR

BLOOD LACTATE

CRP

PROVISIONAL DIAGNOSIS:

LEFY PYELONEPHRITIS 

ACUTE ON CHRONIC PANCREATITIS 

ALCOHOLIC LIVER DISEASE 

TYPE 2 DM 

TREATMENT:

1)NBM TILL FURTHER ORDERS 

2)IVF NS @80ML/HR 

3)INJ PIPTAZ  2.25GM IV/TID

4)INJ PAN 40MG IV/OD/BBF 

5)INJ ZOFER 4MG IV /BD

6)INJ THIAMINE 200MG IN 100ML NS IV/BD

7)INJ TRAMDOL 1Amp IN 100ML NS IV/BD 

8)INJ HAI S/C  TID ACC TO GRBS 

9)INJ NEOMOL 1GM IV /SOS IF TEMP >101F

10)TAB PCM 650MG PO/ TID 

11)TAB CREON PO/OD

12)SYP CREMAFFIN 20ML PO/BD

13) MONITOR VITALS BP,PR,RR,TEMP ,GRBS