This is an online E logbook 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 an available global online community of experts 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 the comment box are 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.
Following is the view of my case :
Date of admission :28-8-2022
Cheif complaints : A 23yr male patient came to opd with cheif complaints of fever since 1week,abdominal pain subconjunctival hemorrhage b/l, rashes on both thighs and abdomen
History of present illness :The patient was apparently asymptomatic 1week back and then developed fever which is low grade, not associated with Pain abdomen for which he went to local hospital and treated symptomatically. There is history of vomiting 2episodes on day2 of fever, and constipation for 2days,4days ago. On 28/8/22 morning he noticed redness in left eye and erythematosis rash over the inner side of both thighs and diffuse pain abdomen since 1week which is more in umbilical and right hypochondrial region
History of past illness
Not a known case of Hypertension, diabetes, epilepsy, CAD, asthma, thyroid.
Personal history:
Diet - mixed
Appetite - normal
sleep - adequate
Bowel and Bladder movements - regular
Addictions - no
No known allergies
Family history :
No significant family history
General examination :
Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person
at the time of examination
He is examined in a well lit room, with consent taken.
He is moderately built and well nourished.
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
lymphadenopathy - absent
Pedal edema - absent
Systemic examination :
Temp -febrile (99.2 f)
PR-92bpm
RR-20 cpm
Bp-110/70 mm hg
Cvs-s1 S2+
CNS-NAD
P/A- soft ,non tender
R/s- BAE+
CVS : S1 and S2 heart sounds heard
NO murmurs and thrills
RESPIRATORY SYSTEM : BAE clear
CNS : NAD
ABDOMEN : Soft and non tender
No palpable masses
NO organomegaly
Investigations:
Treatment:
1. IVF 1 unit NS , RL @ 100ml /hr
2.Inj doxy 100mg Iv bd
3.Tab. DOLO 650 mg PO TID SOS
4.Inj neomol 1gm iv sos
5.Temperature monitoring every 4th hourly.
6.Syrup grillinctus 10ml po tid
7.Tab. atavax 25mg po od
8.Inj Optineuron 1amp 100ml ns
9.Monitor vitals and inform sos
10.Strict I/O charting
Advice at discharge
1.Inj doxy 100mg Iv bd
2.Tab. DOLO 650 mg PO TID SOS
3.Syrup grillinctus 10ml po tid
4.Tab. atavax 25mg po od
5. TAB naproxine 250mg po/sos
Prov.Diagnosis - dengue hemorrhagic fever
Comments
Post a Comment