60 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 60 year old male farmer by occupation, resident of nalgonda came to the casualty with the chief complaints of

  • Fever since 5 days
  • Decreased appetite since 5 days
  • Constipation since 4 days
Patient was apparently asymptomatic 5 days ago then developed fever (low grade) associated with chills and rigor since 5 days
C/o decreased appetite since 5 days
Constipation since 4 days
Increased frequency of micturition (+) since 1 month
Headache, diffuse in nature- on and off since 1 week
No bleeding manifestations 
No dark coloured stools
Red urine negative
Sob negative, palpitations negative
Chest pain negative

Past history
Not a known case of HTN, DM, TB, asthma, epilepsy
No past surgical history
No known allergies

Personal history

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

Family history
No significant family history

Provisional diagnosis
Viral pyrexia with thrombocytopenia

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 distended
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- 15.1
TC- 7300
Neutrophils- 60
Lymphocytes- 35
Eosinophils- 0
Monocytes- 5
Basophils- 0
PCV- 43.6
MCV- 88.2
MCH- 30.5
MCHC- 34.6
RDW-CV- 14.6
RDW-SD- 47.7
RBC count- 4.94
PLT- 15000

Blood for MP STRIP TEST
Negative

Blood grouping and RH typing
O POSITIVE

ESR- 60

Serum electrolytes
Sodium- 136
Potassium- 3.5
Chloride- 98

RBS- 81

Blood urea- 192

Serum creatinine- 3.2

Liver function tests
Total biluribin- 5.55
Direct bilirubin- 4.28
SGOT(AST)- 191
SGPT(ALT)- 90
ALP- 804
Total proteins- 6.0
Albumin- 2.24
A/G ratio- 1.27

Serology
Negative

PT- 20 sec
INR- 1.4
APTT- 41 sec

MP Strip method- Negative

UKB- Negative

Rapid dengue- Negative

Chest xray




ECG


USG abdomen



2D ECHO


Temperature charting




Diagnosis
Viral pyrexia with thrombocytopenia with viral hepatitis

Treatment
1. IV fluids- NS, RL @ 75 ml/hr
2. Inj. Ceftriaxone 1 gm IV BD
3. Tab. Doxy 100 mg PO BD
4. Tab. ULTRACET 1/2 tab PO/QID
5. Tab. DOLO 650 mg/ PO/TID
6. Inj. PAN 40 mg IV/ OD
7. Inj. ZOFER 4 mg IV SOS
8. Inj. Neomol 1 gm/ IV/ SOS
9. Plenty of oral fluids

SOAP Notes
Day 1 (28/10/22)
S
Fever
Decreased appetite
Constipation

O
Patient is conscious, coherent, cooperative

Temp - 98.2 F
BP- 110/80 mmHg'
PR- 78 bpm
RR- 19 cpm
SPO2- 97

A
Viral pyrexia with thrombocytopenia with viral hepatitis

P

1. IV fluids- NS, RL @ 75 ml/hr
2. Inj. Ceftriaxone 1 gm IV BD
3. Tab. Doxy 100 mg PO BD
4. Tab. ULTRACET 1/2 tab PO/QID
5. Tab. DOLO 650 mg/ PO/TID
6. Inj. PAN 40 mg IV/ OD
7. Inj. ZOFER 4 mg IV SOS
8. Inj. Neomol 1 gm/ IV/ SOS
9. Plenty of oral fluids

Day 2 (29/10/22)
S
Fever
Decreased appetite
Constipation

O
Patient is conscious, coherent, cooperative

Temp - 98.2 F
BP- 100/80 mmHg'
PR- 76 bpm
RR- 24 cpm
SPO2- 96

A
Viral pyrexia with thrombocytopenia with viral hepatitis

P

1. IV fluids- NS, RL @ 75 ml/hr
2. Inj. Ceftriaxone 1 gm IV BD
3. Tab. Doxy 100 mg PO BD
4. Tab. ULTRACET 1/2 tab PO/QID
5. Tab. DOLO 650 mg/ PO/TID
6. Inj. PAN 40 mg IV/ OD
7. Inj. ZOFER 4 mg IV SOS
8. Inj. Neomol 1 gm/ IV/ SOS
9. Plenty of oral fluids


Day 3 (30/10/22)
S
Fever
Decreased appetite
Constipation

O
Patient is conscious, coherent, cooperative

Temp - 98.2 F
BP- 110/80 mmHg'
PR- 80 bpm
RR- 22 cpm
SPO2- 96

A
Viral pyrexia with thrombocytopenia with viral hepatitis

P

1. IV fluids- NS, RL @ 75 ml/hr
2. Inj. Ceftriaxone 1 gm IV BD
3. Tab. Doxy 100 mg PO BD
4. Tab. ULTRACET 1/2 tab PO/QID
5. Tab. DOLO 650 mg/ PO/TID
6. Inj. PAN 40 mg IV/ OD
7. Inj. ZOFER 4 mg IV SOS
8. Inj. Neomol 1 gm/ IV/ SOS
9. Plenty of oral fluids



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