A 40 yr old man with dengue and thrombocytopenia

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 centred online learning 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.

A 40 yr old man came to OPD with chief complaints of fever since 2 days.

History of presenting illness:

Patient was asymptomatic 2 days back and developed high grade fever and not associated with chills and rigor.Fever is continuous type.it is relieved on medication,for which he went to local hospital and found the platelet count is too low(35,000platelets /microlitre) and admitted here.

No history of cough,cold.

No history of burning micturition.

No history of vomitings,Loose stools.

History of past illness:

Not a known case of hypertension, TB, CAD, asthma ,DM.

Personal history:

Sleep adequate

Normal appetite 

Regular bowel and bladder movements

No allergies, addictions.

Family history:

Not significant

General examination:

Patient was conscious coherent cooperative

Vitals:

Temperature:98.6F

Pulse rate:90bpm

Respiratory rate:18cpm

BP:100/70 mm Hg

Spo2: 98%

GRBS:99 mg%

No pallor,clubbing, cyanosis, icterus, lymphadenopathy 

Systemic examination:

CVS:

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No

Respiratory system:

Dyspnoea:No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Abdomen:

Shape - Scaphoid 

No tenderness, palpable mass, 

No Fluid 

No bruits

Liver not palpable 

Spleen not palpable. 

Bowel sounds present.

CNS:

Conscious coherent cooperative. 

Speech normal.

No signs of meningitis 

Cranial nerves, motor system, sensory system Normal. 

Provisional diagnosis:

DENGUE with NS1 positive  and THROMBOCYTOPENIA.

Investigations:

28-08-2022:

haemogram


29-08-2022:

Morning -

Evening:

30-08-2022:


31-08-2022:


01-09-2022:


Fever chart:


Treatment:

IVF - normal saline, RL -100ml/hr

Inj. OPTINEURON 1 ampoule 100ml NS IV/OD

Inj.PAN 40mg IV/OD

Inj.ZOFER 4mg IV/SOS

Tab. DOXY 100mg BD

Tab.DOLO 650mgTID

Inj.NEOMOL 1gm IV/SOS.

Strict I/O charting

Repeated hemogram12hrly

Monitor vitals and inform sos.







Comments

Post a Comment

Popular posts from this blog

55 yr old male with CKD 2° to DM

Image
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 centred online learning 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. A 55 yr old male from suryapet  came with chief complaints of generalized body swelling since 15 days,shortness of breath since 15 days, decreased urine output since 10 days. History of presenting illness: Patient was apparent
Read more

prefinal OSCE

https://nagameghana68.blogspot.com/ OSCE   1.How sugar turns into fat in liver? Since your body can only store  required glycogen, if you eat a lot of sugar more than your muscles and liver can hold at one time—your body needs another place to put the excess. In that case, it converts that extra glucose into fat through a chemical process called lipogenesis. This fat is stored under the skin (subcutaneous fat), around your abdominal organs (visceral fat), or in certain other organs such as your liver. If glycogen is like a checking account, then fat is your body’s savings account. It hangs onto this fat in case you use up your glycogen stores. Sugar isn’t the only compound your body can turn into fat. If you eat too much protein, the extra protein gets stored as fat, too. Like sugar, protein contains calories, so if you take in more calories than you burn, the excess protein is converted first into glycogen and then into fat. Still, you’re more likely to store sugar as fat than protein
Read more

68 Naga meghana

  Bimonthly blended assessment October 2021  I have been given the following cases 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, diagnosis and treatment plans. Link to following cases : https://medicinedepartment.blogspot.com/2021/10/oct-2021-formative-bimonthly-blended.html?m=1 Gastroenterology https://vamsikrishnarollno16.blogspot.com/2021/10/a-case-of-64yrs-old-male-patient-with.html?m=1 The blog was brief and clear.All the history and examination was well explained. CNS http://keelasreevalli.blogspot.com/2021/09/a-52-yr-old-female-homemaker-by.html The blog was understandable.All the investigations were depicted nicely and the photographs were also included which made the blog perfect. Haemotology https://mahithguduri63.blogspot.com/2021/09/pancytopenia-under-evaluation.html?m=1 The blog made was very nice.Daily exami
Read more