70 yr old female with fever under evaluation with AKI

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CBBLE UDHC Similar case




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 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 inputs on the comment box is welcome."I've 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 a diagnosis and treatment plan

70 yr old female came with complaints of fever since 1month which is on &  off intermittent. C/o fever associated with chills since 4 days
No c/o vomitings, loose stools, burning micturition, Sob, cough


HISTORY OF PAST ILLNESS: 

N/k/c/o of Htn, Dm, BA, TB, EPILEPSY, CVA , THYROID DISORDERS . 


 PERSONAL HISTORY : 
Diet : mixed
Appetite : normal
Sleep : adequate 
Bowel & bladder habits : regular
                                    
No known addictions 

EXAMINATION : Pt is c/c/c
VITALS : 
TEMP : 99.6 f
HR : 86 bpm
BP : 140/80 mm hg
RR : 18cpm
SPO2 : 98 % @RA
GRBS: 110 mg/dl 

 
CVS : s1, s2 + . No murmurs 
RS : bae + NVBS + 
CNS  : NAD
P/A : soft,non tender




Diagnosis :  Fever under evaluation with AKI 

TREATMENT : 

1) IVF NS, RL@50 ml/hr
2) Inj. Piptaz 2.5gm IV TID
3) Inj. Optineuron 1 amp+100 ml NS IV /OD
4) Inj. Pantop 40 mg IV /OD
5) Inj. Neomol 1 gm IV SOS
6) T. Dolo 650 mg PO SOS
7) T. Nodosis 500 mg PO/TID
8) T. Doxy 100 mg PO/BD
9) plenty of oral fluids





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