Final practical medicine short case
This is 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 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 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 diagnosis and treatment plan.
Registration number-1701006182
52 year old male with fever and thrombocytopenia
Case:
A 52year old male patient came to the opd with Cheif complaint
- Fever since 4days
- Abdominal distension since 3days
- AbdominalPain since 3days
HISTORY OF PRESENTING ILLNESS
- Patient was apparently asymptomatic 4 days ago.
- He then developed fever of low grade, sudden in onset, gradually progressive and relieved on medication.
- He also had complaints of abdominal distension which was gradual and progressive in nature. It is associated with pain. Abdominal pain aggravated on intake of liquids, solids.
- Abdominal tightness is also present.
- before admission in our hospital he went to nearby hospital where he diagnosed with thrombocytopenia
- No history of rashes
- No history of headache ,vomitings, generalised body pains
- No history of loose stools , pain abdomen
- No history of weight loss
PAST HISTORY
Not a k/c/o of DM ,HTN,TB ,ASTHMA,cva
PERSONAL HISTORY
Diet-mixed
Appetite-decreased
Sleep-adequate
Bowel and bladder-regular
Addictions- occasional alcoholic (90ml)and toddy
Toddy intake 8days
GENERAL EXAMINATION
Patient is conscious coherent cooperative well oriented to time place person
Moderately built and nourished
No pallor ,icterus,cyanosis,clubbing,lymphadenopathy,edema
Vitals
Temperature-afebrile
Pulse-85 bpm
Repiratory rate-20 cpm
Bp-120/80 mmHg measured in supine position,in left upper arm .
Spo2:98%at room air
Grbs-120 mg/dl
Abdominal examination-
Inspection:
Skin - smooth (scar from childhood)
Shape - distended
Umbilicus - normal
Abdominal wall movements - present
No visible pulsations and peristaltic movements seen.
Palpation:
Tenderness - mild
No rise of temperature
Liver - not palpable
Spleen - mild palpable
Gall bladder - not palpable
Kidneys - not palpable
Percussion:
Liver - dull note
Spleen - dull note
No shifting dullness, fluid thrill.
Auscultation:
Bowel sounds heard.
No bruit.
CARDIOVASCULAR SYSTEM-
The chest wall is bilaterally symmetrical.
No dilated veins, scars or sinuses are seen
Apical impulse or pulsations can be appreciated in sixth intercostal space 2cms lateral to mid clavicular line
No parasternal heave or thrills are felt
S1 and S2 heard, nomurmurs are heard
RESPIRATORY SYSTEM-
Inspection-
Chest is bilaterally symmetrical
The trachea is positioned centrally
Apical impulse is not appreciated
Chest moves normally with respiration
No dilated veins, scars or sinuses are seen
Palpation-
Trachea is felt in the midline
Chest moves equally on both sides
Apical impulse is felt in the sixth intercostal space
Tactile vocal fremitus- appreciated
Percussion-
The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.
They are all resonant.
Auscultation-
Normal vesicular breath sounds are heard
Central nervous system:
No abnormalities detected
INVESTIGATIONS
Complete blood picture-
Hb-14.9g%
WBC-10,500 cells/mm3
Platelets-17000/mm3@outside hospital report
On 8/06/22:
Hemogram:
Hb-14.9
TLC-10,500
N-43
L-48
E-01
RBC-5.02
PLT-22,000
Blood urea-59
Serum creatinine-1.6
Serum Electrolytes-
Na+ :141
K+ :3.9
Cl- :103
LFT
Total bilirubin -1.27
Direct bilirubin -0.44
SGOT-60
SGPT-47
ALP-127
Total protein-5.9
Albumin-3.5
A/G ratio-1.48
CUE
ALbumin- ++
Pus cells -4.6
Epithelial cells:2-3
NS1 ANTIGEN - POSITIVE
SEROLOGY -IgM and IgG negative
on 9/06/22-
Hb- 14.3g%
Platelets- 30,000/cumm
On 10/06/22-
Hb-14.0 g%
Platelets-84000/cumm
Impression-
GRADE 2 FATTY LIVER
MILD SPLENOMEGALY
RIGHT SIDE PLEURAL EFFUSION (MILD)
MILD ASCITES
ECG
PROVISIONAL DIAGNOSIS
Viral pyrexia with thrombocytopenia
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
*On 10/06/22;
Iv fluids - 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
*On 11/06/22-
Iv fluids - 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
DOLO 650mg /sos
VITALS monitoring
On 12/06/22
Diagnosis-viral pyrexia with thrombocytopenia
With.mild ascites and pleural effysion
Treatment:
Iv fluids - 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
DOLO 650mg /sos
VITALS monitoring
13/06/22
Diagnosis-viral pyrexia with thrombocytopenia
Complaints-no fever spikes
Abdominal distension decreased
No bleeding manifestations
14/06/22
Diagnosis-Viral pyrexia with thrombocytopenia (resolving)
No fresh complaints
Treatment:
Iv fluids - 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
DOLO 650mg /sos
VITALS monitoring
