A 20yrs old male patient

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 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. 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 evident based input.




This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.




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 diagnosis and treatment plan.



Unit 1 admission


A 20 yrs old male patient daily laborer  by occupation came to casuality with cheif complaints  fever  since  yesterday , head ache since yesterday

Patient was apparently asymptomatic yesterday, came with cheif complaints of fever around yesterday night, high grade fever associated  with chill and rigor on , off relieved on medication , no history of cold, cough.

History of head ache since yesterday , pain in frontal region, throbbing type of pain , during episodes of fever, photophobia + and phonophobia + aggrevating with position variation, lacrimation(-), diplopia(-).

No history of nausea, vomiting, loose stools

No history of  chest pain, palpitation, syncopal attacks

No history of sob, orthopnea, palpitation

No history of pedal edema, facial puffiness

No history of burning micturition


Past history:

No history of similar complaints in past 

Not a known case of dm, htn, tb, asthma , epilepsy

No history of previous surgeries and no history of previous blood transfusions


Personal history:

Diet: mixed

Appetite: normal

Bowel, bladder habits : normal, regular

Not a smoker, alcoholic



Vitals : 

Patient was C/C/C

PR :  84BPM.

RR : 18 CPM

BP : 90/60 mm of Hg. 

Spo2 : 99 % at RA. 

GRBS : 99 mg/dl 


On Examination : 

Patient is  thin built and malnourished. 

No pallor

No icterus, cyanosis, lymphadenopathy, Clubbing, pedal edema


Systemic Examination : 

CVS: S1, S2 heard, No murmurs. 

 RS:  Position of trachea : Central 

 BAE : +  

 NVBS Heard. 

 P/A : Soft, Non Tender, No palpable masses or swelling. 

 CNS : NAD. 


Diagnosis: dengue

On 15/8/2021


                                     Ecg





Fever chart



Hemogram
           

Dengue antigen test

ESR

                                          

Malaria parasite


CUE



Serum protein


                                      SGPT


                                       SGOT


                                SERUM BILIRUBIN



                                SERUM CREATININE








SEROLOGY




                               

Diagnosis: dengue

Treatment given:
 1) Iv fluids
2) tab pcm 650 mg po/ tid
3) Inj neomol 1g/ iv/ sos
4) Inj pan 40 mg / po/ od
5)Inj zofer 4 mg iv/ sos

 
 





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