Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input
This E blog also reflects my patient-centered online learning portfolio and your valuable inputs on the 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.
CHIEF COMPLAINTS: FEVER SINCE 15 DAYS ASSOCIATED WITH CHILLS AND RIGOR
CONSTIPATION SINCE 4 DAYS
BLOOD IN URINE SINCE 3 DAYS
1 EPISODE OF BLACK COLORED STOOL - 3 DAYS BACK
HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS BACK , THEN HE DEVELOPED HIGH GRADE FEVER ASSOCIATED WITH CHILLS AND RIGOR WITH EVENING RISE OF TEMPERATURE.
1 EPISODE OF VOMITING
BLOOD IN URINE SINCE 3 DAYS
1 EPISODE OF BLACK COLORED STOOLS - 3 DAYS BACK
NO H/O COLD,COUGH, BLEEDING FROM GUMS
NO H/ O BURNING MICTURITION
PAST HISTORY: NOT A KNOWN CASE OF HTN/DM/ASTHMA/CAD/EPILEPSY.
PERSONAL HISTORY : SINGLE, STUDENT
APPETITE - NORMAL
DIET- MIXED
BOWELS- REGULAR
MICTURITION - NORMAL
BLOOD IN URINE
NO KNOWN ALLERGIES
NO ADDICTIONS
FAMILY HISTORY: NOT SIGNIFICANT
PHYSICAL EXAMINATION: NO PALLOR, ICTERUS,CYANOSIS, CLUBBING, LYMPHADENOPATHY,ODEMA.
VITALS AT THE TIME OF ADMISSION:
TEMP: 102.8 F
PR:128 BPM
BP- 100/80 MM OF HG
RR: 20 CPM
GRBS: 119 MG/DL
SYSTEMS EXAMINATION
CVS: S1,S2 HEARD
NO THRILLS,NI MURMURS
RS: TRACHEA- CENTRAL
BAE+
NVBS
P/A : SCAPHOID,NO TENDERNESS
NO ORGANIMEGALY
BOWEL SOUNDS HEARD.
CNS:
CONCIOUS
SPEECH- NORMAL
NO MENINGIAL IRRITATION
(CRANIAL NERVES,MOTOR SYSTEM, SENSORY SYSTEM ) - INTACT
REFLEXES
RIGHT LEFT
BICEPS- + +
TRICEPS- + +
SUPINATOR- + +
KNEE- + +
ANKLE- + +
PLANTAR- + +
PROVISIONAL DIAGNOSIS: PYREXIA WITH THROMBOCYTOPENIA
INVESTIGATIONS:
DIAGNOSIS: VIRAL PYREXIA WITH THROMBOCYTOPENIA
TREATMENT:
1. IV FLUIDS NS ,RL @100 ML /HR
2. T.DOLO 650 MG PO/TID
3.INJ.NEOMOL 1 GM IV/SOS
IF TEMP >= 101 F
