General medicine case 5

 


 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
 
A 50 yr old male patient farmer by occupation presented to the opd with chief complaints of fever , cough , loose stools since 1 month

HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 20 days back then he developed fever which is low grade intermittent type and associated with chills and rigor since 1 month and not associated with headache ,nausea and vomiting

Initially patient had dry cough since 10 days then he had continuous wet cough   (with sputum) since 20 days .loose stools watery in consistency green to yellow in colour multiple epidoses immediately after food /fluid intake , high volume not associated with abdominal pain and vomiting
 
Patient also complaints of loss of appetite and reduced sleep  since 20 days and weight loss more than 20 kgs 


HISTORY OF PAST ILLNESS
There is no history of hypertension, diabetes mellitus , tuberculosis, asthma, and epilepsy
There is no history of surgery

PERSONAL HISTORY
Diet is mixed 
Sleep is reduced
Bowel - loose stools
Loss of appetite 
There is no history of allergies to known drugs
Patient is non alcoholic and non smoker
He is married and has 2 children


FAMILY HISTORY
There is no history of similar complaints in the family members

GENERAL EXAMINATION
The patient is conscious, coherant and uncooperative. He is well oriented to time , place and person . Moderately built and nourished
No anemia 
No Pallor 
No icterus
No cyanosis
No clubbing
No generalized lymphadenopathy

VITALS

Vitals 
PR 82bpm
RR 20cpm
BP 100/70mmHg
SpO2 98% in room air
GRBS 105mg/dl
Temperature febrile

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Inspection: 

Chest wall is bilaterally symmetrical

No Precordial bulge

No visible pulsations, engorged veins,scars, sinuses

Palpation:

JVP - normal

Apex beat : felt in the left 5th intercostal space

In midclavicular line 

Ausculation:

S1 ,S2 Heard


RESPIRATORY SYSTEM

Bilateral airway +

Position of trachea- central

Normal vesicular breath sounds - heard

No added sounds


PER ABDOMEN

Abdomen is soft and non tender 

Bowel sounds heard

Free fluid grade 1 ascites 


CENTRAL NERVOUS SYSTEM

Patient is conscious 

Reflexes are normal 

Speech is normal

INVESTIGATION





                 

                                 

                     


               

         

   





                                                                                                                                                                                                                                                                                                                                                                                    

Oral candidiasis - tongue 

                       DIAGNOSIS
HIV Positive

TREATMENT
IVF- normal saline 75 ml/hr;Ringer lactate 75ml/hr
Inj metrogyl 100ml/IV/TID
Inj pantop 40mg IV/ BD
Tab Ciprofloxacin 400mg po/BD
Tab bactrim-DS/po/BD
Syrup grilinctus 15 ml po/BD
ORS sachets
Vitals monitoring
Temperature charting

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