45 year old male with Fever
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Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This Elog also reflects my patient centered online learning portfolio.
I have 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.
A 45year old Male Resident of Nalgonda farmer by occupation came with chief complaints of
Fever since 4 days
Cough since 3 days
Pain abdomen since 3 days
History of present illness
Patient was apparently alright 4 days back when he developed fever which was Insidious in onset high grade Intermittent in nature relived by medication not associated with chills or rigors
He also complained of cough non productive in nature progressive no aggrevating or relieving factors
Pain abdomen was diffuse Throbbing type relieved by medication
He complains of generalised body pains
No h/o vomitings, loose stools
No h/o joint pains
He wnt to physician in nalgonda where HRCT was done in which upper lobe posterior segment consolidation was interpreted and was referred to Narketpally.
Past history
No history of Hypertension Diabetes Bronchial Asthama Tuberculosis Epilepsy
Personal history
Appetite normal
Takes mixed diet
Bowel bladder regular
Occasional Alcoholic
No known food or drug allergies
Family history
Not significant
General physical examination
After well informed consent patient was examined in well illuminated light
Patient is conscious coherent and coperative well oriented to time place and person
Moderately built and moderately nourished
Vital data
BP 110/90 Mm hg
Temperature febrile
Respiratory rate 17 cpm
Spo2
No signs of
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Systemic examination
CNS EXAMINATION
Higher motor functions intact
CVS EXAMINATION:
Cardiac sounds S1 S2 heard
No murmers heard
RESPIRATORY SYSTEM
Normal vesicular breath sounds heard
Trachea: central
No wheeze
ABDOMEN EXAMINATION:
Shape of abdomen: scaphoid
No tenderness
No palpable mass
Liver not palpable
Investigations
Ecg
Provisional diagnosis
Dengue with NS1 postive and thrombocytopenia( 60000)
With left upper lobe posterior segment consolidation
On 30 /10/21
Iv fluids @100 ml per hour
Inj pantop 40 mg od
Inj Augmentin 1.2 gm iv tid
Tab Azee 500 mg
Tab Dolo 650 mg OD
Inj Optineuron 1amp in 100 ml Ns/
Inj Neomol 1 gm iv Sos
Monitor vitals
Syp Benadryl 10ml po tid
On 1/11/21
Iv fluids @100 ml per hour
Inj pantop 40 mg od
Inj Augmentin 1.2 gm iv tid
Tab Azee 500 mg
Tab Dolo 650 mg OD
Inj Optineuron 1amp in 100 ml Ns/
Inj Neomol 1 gm iv Sos
Monitor vitals
Syp Ascoril 10ml po tid
W/f bleeding manifestations
Ďaily platelet count pcv
On 2/11/21
Iv fluids @100 ml per hour
Inj pantop 40 mg od
Inj Augmentin 1.2 gm iv tid
Tab Azee 500 mg
Tab Dolo 650 mg OD
Inj Optineuron 1amp in 100 ml Ns/
Inj Neomol 1 gm iv Sos
Monitor vitals
Syp Ascoril 10ml po tid
W/f bleeding manifestations
Ďaily platelet count pcv
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