Final practical medicine short case

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:
Bowel sounds heard. 

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 



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