This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .
I’ve 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.
Registration number:1701006174
Case:
A 52year old male patient came to the opd with Cheif complaints :
Fever since 4days
Abdominal distension since 3days
AbdominalPain since 3days
History of present illness:
Patient was apparently asymptomatic 4days back then he developed fever which is of low grade , continuous in Nature,not associated with chills and rigors,no aggravating factors, relieved on medication.
He then developed abdominal distension which is insidious in onset, progressive type associated with pain .
Before admission in our hospital he went to near by hospital where he diagnosed with thrombocytopenia.
No history of headache, vomiting, generalized body weakness
No history of loose stools, weight loss
Pasthistory:
No similar complaints in the past
Not a known case of Diabetesmellitus,Hypertension, asthma,Epilepsy,cardiovascular disease.
Personal history :
Diet :mixed
Appetite:decreased
Bowel and bladder movements:normal
Sleep:adequate
Occasional drinker
No significant weight loss
No history of allergies.
Family history: nonsignificant
GENERAL EXAMINATION:
Patient is examined with an informed consent and in a well illuminated room
Patient is conscious, coherent and cooperative, well oriented to time, place and person
Moderately built and moderately nourished
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy
Vitals:
TEMPERATURE:afebrile
PR:84bpm
RR:22cpm
BP:110/70mmhg
Systemic examination:
CVS:
S1,S2 sounds heard,no murmurs
Respiratory system:
Bilateral vesicular breath sounds heard
CNS:
Higher mental functions are normal,sensory, motor and Cranial nerves are intact.
Abdominal examination:
Inspection:
Shape:distended
Flanks full dilated
Umbilicus:inverted
Skin is normal
no visible peristalsis
No visible pulsations
No scars and sinuses
Palpation:
No local rise of temperature
Tenderness-slightly
Liver-not palpable
Spleen:not palpable
No palpable mass
Percussion :
Dull note heard
Auscultation:
Provisional diagnosis:
Viral pyrexia with thrombocytopenia
INVESTIGATIONS-
Complete blood picture-
Hb-14.9g%
WBC-10,500 cells/mm3
Platelets-17000/mm3@outside hospital report
On 8/06/22:
Platelets-22000 /cumm
Neutrophils -43%
Lymphocytes -48 %
Eoisinophils -01%
Blood urea-59 mg/dl
Serum creatinine -1.6mg/dl
Serum electrolytes:
Na-142 mEq/l
K-3.9mEq/l
Cl-103 mEq/l
Liver function tests-
Total bilirubin-1.27 mg/dl
Direct bilirubin-0.44 mg/dl
SGOT-60 IU/L
SGPT-47IU/L
ALP-127IU/L
TOtal proteins- 5.9 gm/dl
Albumin-3.5g/dl
A/G ratio-1.48
COmplete urine examination-
Albumin -positive
Pus cells -4-5
Epithelial cells -2-3
NS1 ANTIGEN - POSITIVE
SEROLOGY -IgM and IgG negative
on 9/06/22-
Hb- 14.3g%
Platelets- 30,000/cumm
On 10/06/22-
Hb-14.0 g%
Platelets-84000/cumm
USG-
IMPRESSION- GRADE 2 FATTY LIVER
MILD SPLENOMEGALY
RIGHT SIDE PLEURAL EFFUSION (MILD)
MILD ASCITES
Fever chart
Treatment-
*On 8/6/22
IV FLUIDS - NS AND RL@100ML/hr
Inj.pan 40 mg iv /oD
Inj.optineuron 1 amp in 100 ml Na iv/OD over 30 mins
Inj.zofer 4 mg iv/SOS
VITALS monitoring 4th hourly
*On 9/6/22
Iv fluids - Ns/RL @100 ml/hr
Inj.pan 40 mg iv/OD
Inj.optineuron 1 amp in 100 ml/Ns/iv/OD over 30 mins
Inj.zofer 4mg/iv/sos
Tab.doxycycline 100mg PO/BD
VITALS monitoring
*On 10/06/22;
Iv fluids - NS,RL@100 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 1 amp iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
VITALS monitoring 4 th hourly
*On 11/06/22-
Iv fluids - NS,RL@100 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 1 amp iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
DOLO 650mg /sos
VITALS monitoring