General medicine practical examination short case

 June 10,2022

Final practical:short case

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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 in comment box are most welcomed 


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 a diagnosis and treatment plan.     

June 10,2022

Name :M Sri Sai Pavan.

Hall ticket number;1701006105

Case discussion;

A 52 yr old male , resident of Nalgonda,farmer by occupation,came to the opd on 7/06/22 with chief complaints of 

#  fever since 4 days                                         #abdominal distension  since 3 days

HISTORY OF PRESENT ILLNESS;

He was apparently asymptomatic 4 days back then he developed fever which was insidious in onset low grade type , continuous,relieved on medication,not associated with chills and rigors.associated with loss of appetite 

Abdominal distension -insidious in onset, gradually progressive and not associated with any pain . 

No h/o headache, vomiting,loose stools.

No h/o rash,cough and hemoptysis

No h/o body pains 

No h/o weight loss 

PAST HISTORY;

NO similar complaints in the past.

Not a known case of HTN, TB, ASTHMA,DM,CAD, EPILEPSY.

PERSONAL HISTORY;

DIET; mixed

Appetite: decreased since 3 days

Bowel and bladder; regular

Sleep : adequate

He takes alcohol (90 ml ) and toddy(1 bottle) occasionally.

No known drug allergies.

FAMILY HISTORY;

No similar complaints in the family

GENERAL EXAMINATION;

after taking consent from patient,he examined in a well lit room after adequate exposure.

He is conscious, coherent, cooperative,well oriented to time ,place  and person.

There is  no pallor .







No icterus, clubbing, cyanosis, lymphadenopathy,edema.






VITALS :

Temperature; now Afebrile but @time of admission he is febrile.

PULSE:85 BPM 

RR;20 cpm

Bp;120/80 mmHg measured in supine position,in left upper arm .

Spo2:98%at room air

Grbs;120 mg/dl 

SYSTEMIC EXAMINATION;

PER ABDOMEN;

INSPECTION:

Shape of ABDOMEN;  round and distended

Umbilicus; inverted and central in position

No visible  scars  and sinuses

No engorged veins .

PALPATION;

Inspectory findings are confirmed.

Soft and non tender ,no organomegaly , abdomen is distended .



PERCUSSION; dullness on percussion

AUSCULTATION;

Bowel sounds were heard 

No bruit.

RS;

BAE- PRESENT

NO ADDED sounds

CVS;

S1,S2 heard ,no murmurs 

CNS:intact,NAD

PROVISIONAL DIAGNOSIS;

VIRAL PYREXIA WITH THROMBOCYTOPENIA.

INVESTIGATIONS;

CBP;

Hb;14.9g%

TC;10,500

Platelets;17000/cumm @outside hospital report 

On 8/06/22: 22000 /cumm 

Neutrophils -43

Lymphocytes -48 

Eoisinophils -01

Blood urea-59 

Serum creatinine -1.6mg/dl

Serum electrolytes:

Na-142 mEq/l

K-3.9mEq/l

Cl-103 mEq/l

LFT:

TB-1.27 

DB;0.44

SGOT-60

SGPT-47

ALP-127

TP- 5.9

Albumin-3.5g/dl

A/G ratio-1.48

CUE:

Albumin -positive

Pus cells -4-5 

Epithelial cells -2-3

NS1 ANTIGEN - POSITIVE

SEROLOGY -IgM and IgG negative


Investigations 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 


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 

I/o charting.

*On 10/06/22;

Iv fluids -DNS ,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

I/O charting.

*On 11/06/22;


Iv fluids -DNS ,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










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