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



Comments

Post a Comment

Popular posts from this blog

45 year old male

Image
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 45 year old male who is a construction worker by occupation resident of nalgonda came to the
Read more

45 year old female with altered sensorium secondary to dengue encephalitis

Image
G. Sai Manogna  Roll No 33  This is an online E logbook to discuss our patient's de-identified health data shared after taking her guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from an available global online community of experts to solve those patient's clinical problems with 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.    Following is the view of my case : A 45-year-old woman, a farmer by occupation from Nalgonda has come to the OPD with the chief complaints of  * Fever for 3 days  *Vomitings since 2 day  *ALtered sensorium since 1 day History of presenting illness : In the month of February 2021, the patient has experienced lower abdominal pain for which she visited a hospital and was diagnosed as CA cervix and then hysterectomy was done after which the patient was normal
Read more

44 year old male

 DIAGNOSIS ACUTE DECOMPENSATED LIVER DISEASE SECONDARY TO ALCOHOL WITH GRADE 2 HEPATIC ENCEPHALOPATHY CASE FINDINGS C/O DRAGGING TYPE OF PAIN OF B/L LOWER LIMBS SINCE EVENING DECREASED URINE OUTPUT SINCE 15 DAYS ABDOMINAL DISCOMFORT SINCE 15 DAYS C/O SWELLING OF BILATERAL LOWER LIMBS SINCE 15 DAYS PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS AGO AND THEN DEVELOPED SWELLING OF BOTH LOWER LIMBS, INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, AND ABDOMINAL DISTENSION SINCE 15 DAYS ABDOMINAL DISCOMFORT SINCE 15 DAYS C/O DECREASED URINE OUTPUT SINCE 15 DAYS H/O SEIZURES, 3 EPISODES- ONE IN DEC 2021, JAN 2022, SEP 2022 NOT USED ANY MEDICATION TONIC SEIZURES, UPROLLING OF EYES +, FROTHING FROM MOUTH + POSTURAL CONFUSION + FOR 15 MINUTES SPONTANEOUS URINATION -  SPONTANEOUS DEFECATION - VOMITINGS - LOOSE STOOLS - INCREASED DAYTIME SLEEPINESS SINCE 1 WEEK H/O INCREASED BILIRUBIN LEVELS 1 MONTH BACK HYPERPIGMENTED PATCHES (DIFFUSE) PRESENT OVER THE BODY PAST HISTORY NOT A KNOWN CASE OF HTN, DM, ASTHM
Read more