ACTIVE CLINICAL LEARNING - GENERAL MEDICINE

 Greetings! I'mM.sudarsan sai, a 5th semester medical student. This blog aims at providing cutting edge and wide array of information over the distinguished cases evaluated to the best of my understanding. This blog paces up with the spectrum of patient centered active learning under the guidance of my experienced seniors. Enjoy your reading.A CASE OF SEPSIS PRESENTED IN SUMMER 2022

September 2nd 2022

                                                                     NOTE:

  • The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent.
  • Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
  • This E-log also reflects my patient's centered online learning portfolio.
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 a diagnosis and providing treatment best to our skills and wisdom.    

  A 38 years old man skilled worker by occupation presented in the casualty with complaints of  fever and headache.



CHIEF COMPLAINTs

➤ Fever for last 5 days 

➤Headache for last 5 days

➤Loss of appetite for last 5 days
    
➤Nausea for last 5 days



HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 5years back.  then he was in stress as his brother was having some serious health issues following to which he developed low grade fever and neck pain. then he was diagnosed with hypertension. 
For the last one week patient is having low grade fever associated with chill , headache and neck pain .
No joint pains and  no blurring of vision .Fever was not associated with rashes.


ABDOMINAL EXAMINATION


INSPECTION

➤Shape - Scaphoid

➤Equal movements in all the quadrants.

➤No visible pulsation, dilated veins and localized swellings.

PALPATION

➤Tenderness present in epigastrium

➤Hepatomegaly

CENTRAL NERVOUS SYSTEM EXAMINATION

➤Conscious and coherent

PROVISIONAL DIAGNOSIS : SEPSIS WITH MODS SECONDARY TO BACTERIAL INFECTION


TEMPERATURE CHART



DAY 1

INVESTIGATIONS : 


USG



ECG


TREATMENT

1) IVF NS and  RL 100ML

2) INJ. PANTOP 40MG IV OD

3) TAB.PARACETAMOL 650 MG PO TID

4) INJ. OPTINEURON 1AMP IV OD

5) INJ.NEOMOL 15ML IV SOS

6) INJ. PIPTAZ 2.25MG IV TID

7) INJ. TRAMADOL 1AMP


DAY 2

TREATMENT

1) IVF NS and  RL 100ML

2) INJ. PANTOP 40MG IV OD

3) TAB.PARACETAMOL 650 MG PO TID

4) INJ. OPTINEURON 1AMP IV OD

5) INJ.NEOMOL 15ML IV SOS

6) INJ. PIPTAZ 2.25MG IV TID

7) INJ. TRAMADOL 1AMP


DAY 3

TREATMENT

1) IVF NS and  RL 100ML

2) INJ. PANTOP 40MG IV OD

3) TAB.PARACETAMOL 650 MG PO TID

4) INJ. OPTINEURON 1AMP IV OD

5) INJ.NEOMOL 15ML IV SOS

6) INJ. PIPTAZ 2.25MG IV TID

7) INJ. TRAMADOL 1AMP

8) INJ. ZOFER 4 MG IV SOS

9) TAB DOXY 

10) METOPROLOL


DAY 4

TREATMENT

1) IVF NS and  RL 100ML

2) INJ. PANTOP 40MG IV OD

3) TAB.PARACETAMOL 650 MG PO TID

4) INJ. OPTINEURON 1AMP IV OD

5) INJ. PIPTAZ 2.25MG IV TID

6) INJ. TRAMADOL 1AMP

7) INJ. LASIX

8) TAB DOXY 

9) METOPROLOL

DAY 5

TREATMENT

1) IVF NS and  RL 100ML

2) INJ. PANTOP 40MG IV OD

3) TAB.PARACETAMOL 650 MG PO TID

4) INJ. OPTINEURON 1AMP IV OD

5) INJ. PIPTAZ 2.25MG IV TID

6) INJ. TRAMADOL 1AMP

7) INJ. LASIX

8) TAB DOXY 

9) METOPROLOL

INJ.NEOMOL 15ML IV SOS

INJ. ZOFER 4 MG IV SOS

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