GENERAL MEDICINE E LOG


 NOTE

  • The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent.
  • Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
  • This E-log also reflects my patient's centered online learning portfolio.
  • 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 providing treatment best to our skills and wisdom.


A 43 years old female presented in the casualty with complaints of fever , abdominal pain and vomiting.

CHIEF COMPLAINTs

➤Fever for past 1 week

➤Pain in abdomen and loose stools for past 2 days.

➤Vomiting since yesterday

HISTORY OF PRESENTING ILLNESS

➤Patient was apparently asymptomatic 1 week back then developed fever which was low grade, intermittent and decreased on medication.

➤Loose stools 5-6 episodes per day ?Malena

➤Vomiting 2-3 episodes per day which was non-bilious non projectile with food particles as content.

➤No H/O cough / SOB 

➤No H/O rash over body 

➤No other symptoms

HISTORY OF PAST ILLNESS 

➤No H/O HTN, DM , Epilepsy ,TB , Asthma

➤Patient got MI and had stent.

DRUG HISTORY

➤No significant drug history.

PERSONAL HISTORY

➤Patient takes mixed diet but has a decreased appetite for past 2 days

➤Bowel and bladder movement is normal and regular.

FAMILY HISTORY 

➤No significant family history.

ALLERGIC HISTORY

➤No significant allergic history

GENERAL EXAMINATION 

➤Pallor : Not seen

➤Icterus :  Not seen

➤Cyanosis :  Not seen

➤Clubbing :  Not seen

➤Lymphadenopathy :  Not seen

➤Edema :  Not seen

VITALS

➤Temperature : 96 ℉

➤PR : 101 beats per minute

➤BP : 100/70 mmHg

➤RR : 24 cycles per minute

➤SpO2 : 100 % in room air

SYSTEMIC EXAMINATION 

CARDIOVASCULAR SYSTEM EXAMINATION

➤s1 and s2 heard

➤Thrills absent

➤No cardiac murmurs


RESPIRATORY SYSTEM

➤Normal vesicular breath sounds heard 

 ➤Bilateral air entry present


ABDOMINAL EXAMINATION

➤Abdomen is soft

➤Non tender

➤No palpable mass


CENTRAL NERVOUS SYSTEM EXAMINATION

➤Patient is, conscious, coherent and cooperative.

➤Patient is well oriented to time.

PROVISIONAL DIAGNOSIS : VIRAL PYREXIA WITH THROMBOCYTOPENIA

INVESTIGATIONS :

DAY 1

1.HAEMOGRAM 
             HB: 13.5gm/dl
  TLC:3,700 cells/cumm
PLATELETS:23000cells/cumm


2) RBS 256 mg/dl

3) Serum urea: 13mg/dl

4)Serum.creatinine:0.6mg/dl

5).SERUM ELECTROLYTES
Na:130mEq/L
K:3.6mEq/L
Cl:98mEq/L
6.LFT

                             
DIRECT BILIRUBIN :0.42
TOTAL BILIRUBIN :1.22
AST:16
ALT:10
ALP:237
A/G RATIO:1.20


7.RAPID DENGUE TEST NS1: POSITIVE






CHEST X RAY PA VIEW


ECG



TREATMENT


1. IVF: NS, DNS & RL @100ml/hr continuous infusion

2. Inj. PAN 40 mg/IV/OD

3.Inj.ZOFER 4mg/IV/TID

4. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD

5. Tab. DOLO 650mg/TID.   

6. Watch for bleeding manifestations 

7. TAB.SPOROLAC ds TID

8. BP/PR/spo2 MONITORING

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