Gm final practical short case sheet

  This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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. 

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. 

Date of admission:30/07/2022.

A 45yrs old female ,farmer by occupation is a resident of nalgonda presented to casuality with the Chief complaints Of  Fever and body pains, not associated with chills since 10days.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 13 days ago,then she developed fever which is sudden in onset and intermittent,it is not associated with chills and controlled temporarily on medication.

Patient complaints of dark coloured stools since 3 days(melena),body pains and joint pains since 2 days .

Also complaints of vomtings 1 episode yesterday night which was non projectile and non bilious..

history of loss of appetite since yesterday.

There is no history of rashes, burning micturition,hematuria,hematemesis,

Neck stiffness.

PAST HISTORY

There are no similar complaints in the past.

Not a known case of 

                                 TB

                                 Asthma

                                 Diabetes

                                 Epilepsy

                                 CVA

                                 CAD etc.

PERSONAL HISTORY

Diet-Mixed

Appetite-Normal

Bowel and Bladder movements-Regular

Sleep- adequate

No Addictions either tobacco using or alcohol 

ON EXAMINATION

Patient was conscious, coherent, cooperative and we'll oriented to time place and person

Moderately built.

GENERAL PHYSICAL EXAMINATION

Pallor- present

Icterus- absent

Cyanosis- absent

Clubbing- absent

Generalized lymphadenopathy- absent

Clinical examination :

VITALS**

Temperature- 101.4F

Pulse rate -80bpm

Resp rate - 16cpm

Blood pressure-110/82mmHg

sPo2 98% at room temperature

SYSTEMIC EXAMINATION

CVS: Inspection

Chest wall is bilaterally symmetrical.

No precordial bulge is seen 

Palpation

JVP- Normal

Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 

Auscultation

S1&S2 are heard,no murmurs found.

RESPIRATORY SYSTEM

Dyspnoea- no

No wheezing sounds 

Position of trachea- central

Bilateral air entry, normal vesicular breath sounds are heard.

No added sounds

CVS

Patient is conscious

Speech normal

No signs of meningeal irritating

Motor and sensory system- Normal

Reflexes - present

Cranial nerves - intact

PER ABDOMEN

Liver non palpable

Spleen non palpable 

Soft and Non tender.

FEVER CHART 

INVESTIGATIONS

Hb-11.3

TLC-1500

Platelet count-42000

Rbs-242 & Fbs- 126

Hb1Ac-6.9

Hb-11.6

TLC-2150

Platelet count-75000

PROVISIONAL DIAGNOSIS

VIRAL PYREXIA with thrombocytopenia

TREATMENT

IVF -NS,RL.DNS

Tab- paracetamol 650mg TID

Inj- PANTOP 40 mg

Inj- NEOMAL if temp rises above 102f

Inj-OPTINEURON 1mg Iv