24 year old male

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Name: G Sai Manogna

Roll no 41

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.

Following is the view of my case :

CASE PRESENTATION:

A 24 year old male resident of nalgonda has come to the opd  with the chief complaints of

  • Fever since 6 days (on and off)
  • Decreased appetite since 1 week
Patient was apparently asymptomatic 6 days ago then he developed fever which is of low grade, insidious in onset and gradually progressive and is continuous type associated with chills and rigors and is relieved on taking medication
c/o decreased appetite since 1 week
c/o cough with sputum, greenish white in color since 3 days
c/o pain abdomen, diffuse in nature and is relieved on taking medication
h/o dark colored stools since 3 days
No h/o reddish urine

Past history
No history of similar complaints in the past
Not a known case of HTN, DM, asthma, TB, epilepsy
No history of prior surgeries
No known allergies

Personal history
Diet- Mixed
Appetite- Normal
Bowel and bladder movements- Regular
Sleep- Adequate
Addictions- None


Drug history
No history of use of any medicines without presecription

Family history
No similar complaints in the family

Provisional diagnosis
Viral pyrexia under evaluation

General examination
Done after obtaining consent, in the presence of attendant with adequate exposure
Patient is conscious, coherent, not cooperative but well oriented to time, place and person
Patient is well nourished and moderately built
 
No history of pallor, icterus, cyanosis, clubbing, edema and lymphadenopathy

Vitals
Temperature- Afebrile
Blood pressure- 120/80 mm of Hg
Pulse rate- 78 bpm
Respiratory rate- 18 cpm
SpO2- 98% at room air

Systemic Examination:

Cardiovascular System:
S1 and S2 sounds are heard
No abnormal murmers

Respiratory System:
Bilateral air entry present
Trachea is central
Normal vesicular breath sounds are heard
No adventitious sounds are heard

Abdominal Examination:
Shape of abdomen is scaphoid
Soft and non tender
Bowel sounds are heard
No palpable mass
Hernial orifices are normal
No organomegaly

Central Nervous System:
No focal neurological deficits











Investigations

Hemogram
HB- 17
TC- 8600
Neutrophils- 20
Lymphocytes- 75
Eosinophils-0
Monocytes-5
Basophils-0
PCV-46.4
MCV-92.4
MCH-31.1
MCHC-33.6
RDW-CV-13.0
RDW-SD-46.3
RBC COUNT- 5.02
PLT- 27000

BGT
B POSITIVE

CUE
Colour- Pale yellow
Appearance- Clear
Reaction- Acidic
Sp. gravity- 1.01
Albumin- +
Sugar- Nil
Bile salts- Nil
Bile pigments- Nil
Pus cells- 3-6
Epithelial cells- 2-4
Red blood cells- Nil
Crystals- Nil
Casts- Nil
Amorphous deposits- Absent
Others- Nil

ESR- 10

RFT
Urea- 32
Creatinine- 0.8
Uric acid- 4.2
Calcium- 10.1
Phosphorous- 3.6
Sodium- 141
Potassium- 4.1
Chloride- 103

Liver function tests
Total biluribin- 1.06
Direct biluribin- 0.27
SGOT(AST)- 97
SGPT(ALT)- 61
ALP- 274
Total proteins- 7.1
Albumin- 4.0
A/G ratio- 1.27

DENGUE- POSITIVE

Chest Xray


ECG


USG Abdomen



Temperature charting

Treatment
1. IV fluids- NS, RL @ 125 ml/hr
2. Tab. Doxycycline 100 mg/PO/BD
3. Inj. Ceftriaxone 1 gm/IV/BD
4. Inj. PAN 40 mg/IV/OD
5. Inj. Zofer 4 mg/IV/SOS
6. Tab. PCM 650 mg/PO/SOS
7. Temperature charting 4th hourly
8. Watch for bleeding manifestations

SOAP NOTES
Day 1 (28/10/22)
S
Fever
Decreased appetite
Cough with sputum
Pain abdomen

O

Patient is conscious, coherent, cooperative
Temp - 98.6 F
BP- 120/80 mmHg'
PR- 86 bpm
RR- 22 cpm
SPO2- 94

A
Pyrexia under evaluation secondary to dengue

P
1. IVF- NS, RL@ 125 ml/hr
2. Inj. PAN 40 mg/ IV/OD
3. Inj. Zofer 4 mg/ IV/SOS
4. Temperature charting 4th hourly
5. Strict I/O charting

Day 2 (29/10/22)
S
Fever
Decreased appetite
Cough with sputum
Pain abdomen

O

Patient is conscious, coherent, cooperative
Temp - 99.8 F
BP- 120/80 mmHg'
PR- 84 bpm
RR- 23 cpm
SPO2- 94

A
Pyrexia under evaluation secondary to dengue

P
1. IVF- NS, RL@ 125 ml/hr
2. Inj. PAN 40 mg/ IV/OD
3. Inj. Zofer 4 mg/ IV/SOS
4. Tab. PCM 650 mg/PO/SOS
5. Temperature charting 4th hourly
6. Strict I/O charting
7. Watch for bleeding manifestations
8. Tab. Doxy 100 mg/PO/BD
9. Inj. Ceftriaxone 1gm/IV/BD

Day 3 (30/10/22)
S
Fever
Decreased appetite
Cough with sputum
Pain abdomen

O

Patient is conscious, coherent, cooperative
Temp - 98.6 F
BP- 120/80 mmHg'
PR- 86 bpm
RR- 22 cpm
SPO2- 94

A
Pyrexia under evaluation secondary to dengue

P

1. IVF- NS, RL@ 125 ml/hr
2. Inj. PAN 40 mg/ IV/OD
3. Inj. Zofer 4 mg/ IV/SOS
4. Tab. PCM 650 mg/PO/SOS
5. Temperature charting 4th hourly
6. Strict I/O charting
7. Watch for bleeding manifestations
8. Tab. Doxy 100 mg/PO/BD
9. Inj. Ceftriaxone 1gm/IV/BD







 

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