37 year old male with pain abdomen and fever

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A 37 year old male presented with pain abdomen and fever

K.Lasya Mithra

Roll No: 60

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.

CASE:

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

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 )

INVESTIGATIONS:

Amylase: 27

Lipase: 15

DIAGNOSIS:

PYREXIA UNDER EVALUATION 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.D2 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