38 Year old male with Fever Since 4 days
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.
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