General medicine case 7

01 December 2021

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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. 

Chief Complaint:-

-21 year old female patient resident of janagam homemaker by occupation presented to causality complaints of fever since 5 days .

History of present illness :-

Patient was apparently asymptomatic 5 days back and then she developed chills with  fever ,high grade continuous fever .

Past history :-

-No nausea,vomiting ,cough ,SOB ,No rashes,no bleeding manifestations.

-She is not a known case of diabetic , hypertension.

-No history of epilepsy ,asthama , tuberculosis.

-She had a C section 9 months ago and now she is pregnant(2nd trimester)

Personal history:-

-Apetite-Reduced 

-Diet -Mixed diet 

-Bowel and bladder movements-regular 

-Adequate sleep 

-No addictions 

Family history:-

No similar complaints in the family members 

Treatment history:-

She is not allergic to known drugs 

GENERAL EXAMINATION:-

-Patient was conscious,coherent well oriented to time and place .

-No pallor , icterus,

Cyanosis,clubbing , lymphadenopathy

Vitals :-

-Temperature-afebrile

-RR -20 cycles /min 

-PR- 110 bpm 

-BP-110/9mm hg

SYSTEMIC EXAMINATION:-

CVS-:- 

Inspection -chest wall is bilaterally symmetrical.

No precordial bulge .

No visible pulsations,scars ,engorged veins ,sinuses .

Palpation -JVP is normal 

Auscultation- S1 S2 sounds are heard .

RESPIRATORY SYSTEM:-

-position of trachea is central 

-bilateral air entry is normal 

-normal vesicular breath sounds are heard 

-No added sounds 

 

ABDOMEN:-

-Non tender 

-No palpable mass

-No bruits 

-Liver and spleen are not palpable

CNS :-

-patient is conscious

-speech is present 

INVESTIGATIONS:-

HEMOGRAM:-

-Hb -13.8gm/dl

-Total count -4000cells/cumm

-PCV-39.4%

-MCV-81.4fl

-RBC count -4.8million /cumm

-Platelet count-40000/cumm

SMEAR:-

-RBC -Normocytic Normochromic

-WBC IS within limits 

-Platelets are reduced 

-No hemoparasites detected-

-Impression -Normocytic Normochromic

Picture with thrombocytopenia

Ultrasound report:-

DIAGNOSIS:-

Dengue fever 

Treatment:-

1. IVF NS }100ml/hr

           RL }

2.INJ Neomol 1gm/IV

3.Tab. Dolo 650 mg PO TID

4.Tab. Pan 40 mg PO OD

5.Tab. Doxinate 1 tab PO OD

6.Tab. Fantastic-S PO OD

7.Tab. Calforte-D3 PO HS

8. GRBS 12th hourly

9.BP. PR. TEMP 4th hourly

10.Tab Onden 4mg/PO/BD.