General medicine e log

 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-centred online learning portfolio and your valuable comments 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 a diagnosis and treatment plan. 

CHEIF COMPLAINTS:

 28 years male autodriver by occupation admitted in hospital with c/o fever since 5 days

HOPI:

patient was apparently asymptomatic 5 days back then he developed intermittent low grade fever a/w generalised body pains, headache, and giddiness. Lots of appetite, not a/w chills and rigor no diurnal variation 

No history of malena, hematuria

No complaints of chest, pain, cough, cold

No complaints of burning micturition

No complaints of loose stools, nausea, vomiting

PAST HISTORY :

Not a known case of hypertension, diabetes, thyroid, CAD CVA TB

PERSONAL HISTORY:

Appetite: normal

Diet: mixed

Addictions: no

Sleep: adequate

bowel regular 

General examination:

Pt is conscious, coherent, cooperative

No signs of clubbing, cyanosis, pallor ,icterus,lymphendenopathy 

Vitals :

Bp :120/90mm hg

PR:78bpm

Temp:97.8

RR: 21 cpm

Systemic examination:

Per Abdomen:

Shape of abdomen-distended

Umbilicus -inverted

Abdomen moves accordingly with respiration.

 No sinuses/scars

Abdomen is soft,diffused tenderness

No free fluid

Hernial orifices-Normal

No organomegaly

Bowel sounds- present 

Cardiovascular system: 

Inspection-

Shape of chest-Normal  

No precordial bulge.

No dialated veins,scars and discharging sinuses.

No visible pulsations.

Palpation-

 Apical beat felt in 5th intercostal space.

No parasternal heave and thrills

Respiratory system:

-Inspection:

Trachea -appears to be central

Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.

elliptical in shape.

No chest wall defects.

No scars and sinuses.

-Palpation:

All the inspectory findings are confirmed.

Trachea central 

Tactile vocal

Fremitus                   Right                              Left

Supraclavicular          N                                   N

Infraclavicular           N                                   N

Mammary                   N                                  N

Inframammary          N                                  N  

Axillary                        N                               N

Infraaxillary               N                                N

Suprascapular           N                                N

Infrascapular            N                                N

-Percussion                Right                          Left

Supraclavicular          R                                R

Infraclavicular           R                                R

Mammary                   R                               R

Inframammary          R                               R

Axillary                        R                             R

Infraaxillary               R                             R

Suprascapular           R                              R

Infrascapular             R                             R

R-Resonant

-Auscultation        Right                                       Left 

Supraclavicular     NVBS                                  NVBS

Infraclavicular       NVBS                                 NVBS

Mammary               NVBS                                NVBS

Inframammary      NVBS                                NVBS  

Axillary                    NVBS                            NVBS

Infraaxillary            NVBS                            NVBS

Suprascapular        NVBS                           NVBS

Infrascapular         NVBS                          NVBS

Central Nervous system:

Conscious

Cranial nervers -normal

Tone                 Rt                  Lf 

UL                     N                   N

LL                      N                   N

Power               Rt                  Lf

UL                    5/5                 5/5

LL                     5/5                 5/5

Fine touch       Rt                  Lf 

UL                     N                   N

LL                      N                   N

Reflexes.          Rt.                 Lt

Biceps               ++                 ++

Triceps             ++                  ++

Supinator        ++                  ++

Knee                 ++                  ++

Ankle                ++                  ++

PROVISIONAL DIAGNOSIS :DENGUE FEVER (NS1 &IGM POSITIVE)

Investigations:

Hemogram	21/10/23	22/10/23	23/10/23	24/10/23	25/10/23
Hb	19.1	17.5	16.8	15.6	15.2
TLC	4000	4000	5200	5600	5600
RBC COUNT	6.19	5.81	5.81	5.37	5.22
PLATELET COUNT	18000	40000	20000	28000	52000

TREATMENT:

S/P ONE SDP TRANSFUSION ON 23/10/23

1. IV FLUIDS @75 ML/HR

2.INJ TRAMADOL 1AMPULE IN 100 ML NS IV

3.TAB PCM 650MG PO/SOS