Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. 

A 65 year old female presented with chief complaints of fever,chills since 20days,loose stools since 8days, decreased urine output since 3days
She was apparently asymptomatic 20days back then she developed fever which was intermittent, associated with chills since 10days,bilateral pedal edema since 20days.She was admitted in a hospital in nalgonda where was diagnosed to have renal abcess,black coloured stools since 3days ,loss of appetite since 10days.
Her daily routine was she wakes up at 5am,has her breakfast (java)9amthen goes for agricultural work,rice for lunch at 1pm and for dinner she has chapati.
PAST HISTORY:
 She is k/c/o HTN since 10 years. 

K/c/o DM since 10 years
N/k/c/o TB, ASTHMA, CAD, EPILEPSY. 
Personal history:
Diet- mixed 
Appetite - decreased since 20 days 
Sleep-
Bowel - black coloured stools since 3 days bladder - decreased urine output  

GENERAL EXAMINATION :

patient was concious coherent cooperative and well oriented to time place and person.

Bp:150/90 mm hg 

Pr:123bpm

Grbs:591 mg/dl 

SpO2:88%

CNS: 

Concious

 Speech:normal 

Gait:normal 

No neck stiffness 

Sensory,motor systems are normal

CVS:S1&S2 HEARD

Provisional diagnosis:atypical pnuemonia, diarrhoea ,right kidney abcess, uncontrolled Type 2diabetes with hypertension since 10years.

INVESTIGATIONS:























Treatment:

Plenty of oral fluids 

Inj.Zofer 4mg IV/TID

INJ.PAN 40MG IV/OD 

INJ.DOMPERIDONE 10MG IV/TID 

INJ. HAI SC/TID 

TAB.LINEZOLID 600MG PO/BD









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