43 YR FEMALE WITH CONSTANT ILL HEALTH THOUGHTS

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 is welcome.

Here is a case that I have seen:

GM unit 3 admission on 17/2/21
Interns:
Dr Harsha
Dr Sreeja
Dr Archana
Dr Kalyan 
Dr Sahithi 
Dr Jeehariki

Dr Raveen PGY1
Dr Aashitha PGY2
Dr Aravind PGY3
Dr Vamshi PGY3
Dr Hareen SR
Dr Praveen Naik - Ass. prof
Dr. Rakesh Biswas - HOD 

43/F 
C/o : fever since 1 month on and off
         Burning micturition since 1 month 
         Generalised weakness + 
         Myalgia + 
HOPI:
Patient was apparently asymptomatic 1 month back.
He developed fever which was insidious in onset, intermittent type,  diurnal variation+
Fever was on and off, was on medication(?). 
Burning micturition + since 1 month 
generalised weakness + 
Myalgia + 
No H/O nausea/ vomiting/loose stools 

Past history: k/c/o asthma, on rotahaler (beclamethasone and levosalbutamol) 
Not a k/c/o T2DM, HTN, TB, Epilepsy 

Personal history: 
Diet-mixed
Appetite - decreased 
Sleep- normal 
Constipated , burning micturition + 
Drinks toddy occasionally 

No known drug / allergic history

No significant family history 

On examination: 
Patient was conscious/coherent /co-operative 
Thin built and moderately nourished 
No pallor/icterus/clubbing/cyanosis/generalised lymphadenopathy/pedal Edema 

BP: 110/70mmhg
PR: 98bpm
RR: 18cpm
SPO2: 98% at RA
GRBS-112mg/gl
Afebrile to touch

Systemic examination: 
CVS: s1,s2 heard
RS: BAE present,
P/A: soft, non - tender 
CNS: NAD

Investigations:
Diagnosis : 
?Viral Pyrexia
Treatment:
IVF 1unit NS and 1unit RL @75ml/he
INJ.PAN 40mg IV OD BBF
INJ.PCM 650mg IV SOS
TAB.DOLO 650mg PO SOS
SYP.CITRALKA 10ml in oneglass of water PO BD


20/02/21:
21/2/21:
22/02/21
Psychiatry referral was taken I/V/O constant I'll thoughts :
Diagnosed as Adjustment disorder due to personal issues.

Discussion:

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