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.

A 55 year old female presented with chief Complaints of 

• Fever since 10 days

• Generalised weakness since 10 days

HOPI:

The patient was apparently asymptomatic 10 days ago then she developed high grade fever which was sudden in onset, continuous and fever associated with chills and rigor. No aggravating factors , fever relieved with medication.

Fever associated with Backpain which was insidious in onset, gradually progressive, dull pain , continuous with no aggravating and relieving factors.

There is generalised weakness since 10 days.

She received 2 injections of antibiotics from a RMP intially. Later she was taken to a government hospital where she was told to have low platelet count.

Past History -

Not a known case of Diabetes, Hypertension, Asthma, Tuberculosis, Epilepsy, CAD, Thyroid disorders.

Personal History-

Daily Routine of the patient-



Diet: Mixed

Appetite: Decreased 

Sleep: Normal

Bowel and Bladder Movements: Regular

Addictions- History of Smoking 2 to 3 times a day since the last 40 years. Stopped smoking 20 days back. 

Occasionally Alcoholic since the last 10 years.

Family History: Not Significant 

Drug History: Not Significant

No known allergies.

General Examination:

Patient is concious, coherent and cooperative well oriented to time, place and person. She is well built and we'll nourished.

Pallor- Absent

Icterus- Absent 

Cyanosis - Absent

Clubbing - Absent

Lymphadenopathy- Absent

Bilateral Pedal Edema is present.

Vitals:

Temperature - Afebrile

BP- 100/70

Pulse-81

RR- 14 cpm

Systemic Examination:

Abdominal Examination -

On Inspection:

Abdomen is slightly Distended, no flant fullness, umbilicus is center and slit like. No scars, sinuses visible. No engorged veins.

On Palpation:

All inspectory findings are confirmed on Palpation.

Tenderness is seen on the right hypochondrium region.

Percussion: No Significant Findings

Auscultation: Bowel Sounds heard

Respiratory system:

Bilateral air entry is present 

Normal vesicular breath sounds are heard

CVS:

Inspection:

Position of the trachea is central. 

Apical impulse is not observed. 

No other visible pulsations, dilated and engorged veins,sinuses. 

Palpation:

Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 

Position of trachea was central 

No parasternal heave , thrills, tender points. 

Auscultation: 

S1 and S2 were heard 

There were no added sounds / murmurs.

CNS -

No focal neurological deficit.

Fever Chart-


Clinical Pictures-








Investigations-

Hb- 9.1gm/dl
Dengue IgM +ve

ECG-

USG- No Sonological abnormality detected 

LFT-
Total Bilirubin -4.77 mg/dl
Direct Bilirubin -3.67 mg/dl
SGOT  -125 IU/L
SGPT -77 IU/L
ALP- 915 IU/L
Albumin- 2gm/dl

S.Creatinine- 1.2 mg/dl

Blood Urea- 57 mg/dl

Treatment -
IVF-  1 Ns with 1 amp Optineuron 100ml /hr
IVF-  NS, RL, DNS 150 ml/hr
Inj. NORAD 20 ml in 46 ml NS at 6 ml/hr 
Tab Dolo 650 mg Po/ TID

Provisional Diagnosis -
Dengue with Thrombocytopenia
? AKI
? Acute liver Injury

Comments

Popular posts from this blog