This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent
Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect6current best evidence based input
This Elog also reflects my patient centered online learning portfolio.
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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan
CONSENT AND DEIDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever
Under the guidance of
Dr. Vinay PGY3
Dr . Venkat sai PGY1
This is a case of 38 year old male came with cheif complaints of
1.Fever with chills
2.cold
3.Cough
4.Generalized weakness
5.Head ache(frontal region)
6.SOB grade 2
7. Loose stools
HOPI:-
Patient was apparently asymptomatic 4days back. Then he developed fever which was high grade fever with chills which eas intermittent relieved by medication associated with cold,cough which is dry in nature and generalized weakness.
Since 1 day he has complaints og loose stools of 5 episodes which is watery and non blood stained and non mucoid.No complaints of pian abdomen or vomitings.
PAST HISTORY:-
Not a known case of HTN/DM,
/Thyroid disorder/TB/Asthma/CAD
PERSONAL HISTORY:-
DIET- Mixed
APPETITE- Normal
SLEEP- Adequate
BOWEL AND BLADDER MOVEMENTS - regular
ADDICTIONS -none
FAMILY HISTORY
Not significant
GENRAL EXAMINATION
The patient is coherent, conscious,cooperative well oriented to time place and person
He is moderately built and nourished
PALLOR -absent
ICTERUS -absent
CYANOSIS -absent
CLUBBING -absent
EDEMA -absent
LYMPHADENOPATHY -absent
VITALS :-
TEMP-98.9f
PR-110bpm
RR -22cpm
BP-110/80
Spo2-98%
SYSTEMIC EXAMINATION
CVS-S1S2 heard
CNS-Higher motor functions intact
PA-Soft and non tender
RS- BAE+
DIAGNOSIS-
VIRAL PYREXIA WITH THROMBOCYTOPENIA DENGUE NS1 +
INVESTIGATIONS.-
6/9/22
7/9/22
8/9/22
TREATMENT:-
1. IV FLUIDS 10NS with 1amp OPTINEURON
10RS @75ml/hr
2.INJ NEOMOL 1gm/IV/SOS ( If temp >102f)
3.INJ PAN 40 mg /IV/OD/BBF
4.TAB. DOLO 650mg /PO/SOS
5 BP/PR/ TEMP/SPo2 charting 4th hourly
6.Look for postdural drop
7.Inform SOS
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