38 Year old male with Fever Since 4 days

This is an 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 patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient centered online learning portfolio and your valuable comments on 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 complaints-


36 yr old male patient presented to opd with 

c/o  Fever since 4 days 

C/o of 7 episodes of loose stools 


HOPI-

Patient was apparently asymptomatic  4 days back then developed fever associated with chills and rigor , No diurnal variation,relieved with medication 

C/O Loose stools since yesterday,4-6 episodes/day,non blood stained 

H/O anorexia present since 4 days 

No H/O vomitings, decreased Urine output 

No complaints of PainAbdomen/Or any bleeding manifestations

i.e., Nohematuria/ Melena or  blood

in stool/Bleeding gums

Petechiae /rash.

No SOB/chest pain/palpitations


PAST HISTORY-

Not a k/c/o HTN, DM, CVA, CAD, TB, Asthma, or thyroid disorders. 


Allergic history:-

No history of any kind of allergies to food/drugs


Family history:- 

No significant family history 


GENERAL EXAMINATION:- 

THE PATIENT IS CONSCIOUS COHERENT AND COOPERATIVE 

NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ODEMA ; LYMPHADENOPATHY


TEMPERATURE:- 98.8 F 

PR:81bpm

BP:110/70 mmHg

RR:17cpm












SYSTEMATIC EXAMINATIONS:-


CVS:S1 S2+,NO MURMURS

CNS: NAD

RS:BAE+ ; NVBS 

P/A:SOFT ; NON TENDER ; NO ORGANOMEGALY 








PROVISIONAL DIAGNOSIS:- 

? Viral hemorrhagic fever 

? Dengue

2/9/23-


HAEMOGLOBIN

14

TOTAL COUNT

3,000

NEUTROPHILS

48

LYMPHOCYTES

41

EOSINOPHILS

00

MONOCYTES

10

BASOPHILS

01

PCV

43.8

MCV

81.2

MCH

31.3

MCHC

38.6

RDW-CV

12.7

RDW-SD

35.3

RBC COUNT

5.35

PLATELET COUNT 27000


Total Bilirubin 2.04

Direct Bilirubin 1.22

SGOT(AST) 36

SGPT(ALT) 197

ALKALINE PHOSPHATE  267


UREA 30

CREATININE 1.2 

UC 2.3 

Sodium - 136

Potassium- 3.5

Chloride - 96


NS1 - POSITIVE 

Ig M - negative

Ig G - negative


3/9/23

Hb-14.2

Total count-3000

 Plt count- 23000

 Blood urea- 30

S.creat- 1.3 

S.Na+-131

S.K+ 3.4

S.chloride- 98


SDP transfusion done on 3/8/23 6 pm


4/8/23


Hb- 13.7

Total count- 4,100

Neutrohil-50

Lymphocytes-38 

Eosinophils- 02

Monocytes-10

Basophils- 00

Pcv- 36

Mcv- 82

Platelet count-26000









Treatment-

1.I.v fluids 2 N.S @100 ml/hr

2.Tab.Dolo 650 mg Po/SOS

3.Inj. Neomol 1 gm Iv/ SOS

4.Tab.sporolac Ds Po/TID

5.Tab. Redotril 100 mg Po/OD 

6.Watch for bleeding manisfestations.



Comments

Post a Comment

Popular posts from this blog

1801006072 Long case

Image
This is an 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 patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient centered online learning portfolio and your valuable comments on 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 complaints   A 50 year old male farmer by occupation came to opd with chief complaints of  1. SOB since 10 days 2.Edema of both upper and lower limb since 6 days History of present...
Read more

Evidence based date wise workflow logs collated by the intern with clickable and verifiable link

Image
2) Evidence based date wise workflow logs collated by the intern with clickable and verifiable links As of 19/9/23 :-  CASE 1:- PaJR Group  https://chat.whatsapp.com/Jc43jR1klLF7ovLA3oagvU Blog :-  https://kattaphanikeerthanarollno72.blogspot.com/2023/09/a-70-year-old-male-presented-to-opd.html [05/09/23, 8:54:43 AM] ~ Keerthi Madireddi: @919381040824 update soap notes and also draw a graph showing the potassium values and intervention done. [05/09/23, 8:55:52 AM] Keerthana: Ok mam [05/09/23, 9:02:57 AM] ~ Keerthi Madireddi: @919381040824 please make me and hod sir as admin [05/09/23, 9:04:03 AM] ~ Keerthi Madireddi:  ☝🏻 [05/09/23, 9:46:51 AM] Rakesh Biswas Sir Hod Medicine: Mention duration in the title [05/09/23, 10:40:57 AM] Keerthana: Date-5/9/23 Ward-ICU    Bed 5  Unit 6  Date of admission 2/9/23 S -  C/o weakness in both upper and lower limb, C/o slurring of speech since 4 days  O -  On examination  Patient is conscious ...
Read more

A 21 year old pregnant women with 4days of fever chills and rigor

Image
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 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 21 year old pregnant patient came to OPD with a cheif complaints of fever since 4 days Associated with chills and rigor HISTORY OF PRESENTING ILLNESS- Patient was apparently asymptomatic 4 days back and then she devel...
Read more