This is an online E logbook 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 an available global online community of experts to solve those patients clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are 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.
Following is the view of my case :
Date of admission :27-8-2022
Chief complaints :
A 29-year-old female patient came to the casualty with the cheif complaints of fever and vomitings since 4 days.
History of present illness :
H/o Fever-
Onset - insidious
Duration- since 4 days
Type - intermittant ,low grade
It was relieving on taking medications .
Associated with chills and rigors.
Associated with generalised body aches
Diurnal variation absent
No increased temperature at night
H/0 vomitings 4 days back
One episode
Non-blood stained, non bilious, non foul smelling
Non projectile
Content - water and food
4 days back, she went to RMP in nalgonda and got her reports done which showed,
1. Low platelet count
2. TLC 3,400
...later her relatives adviced her
So she came to our hospital.
Daily routine- wakes up at 5:00 am
Cooks Breakfast and eat's at 8:00 am
Goes to work -she is a agricultural labourer
Lunch at 12:00 pm
Returns from work at 6:00 pm
Takes rest, cooks, does dishes and other works
Sleeps at 10:00 pm
History of past illness :
Not a known case of,
Hypertension, diabetes, epilepsy, CAD, asthma, thyroid.
Personal history :
Diet - mixed
Appetite - normal
sleep - adequate
Bowel and Bladder movements - regular
Addictions - no
No known allergies
Drug history :
No significant drug history
Family history :
No significant family history
General examination :
Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person
at the time of examination
SHe is examined in a well lit room, with consent taken.
SHe is moderately built and well nourished.
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
lymphadenopathy - absent
Pedal edema - absent
Vitals : on the day of admission (27/8/2022)
Temperature - 98.6
Pulse rate - 82 bpm
Respiratory rate - 16 cpm
Blood pressure - 110/80 mmHg
SpO2 - 99.6% on Room air
GRBS - 102 mg/dl
Systemic examination :
CVS : S1 and S2 heart sounds heard
NO murmurs and thrills
RESPIRATORY SYSTEM : Bilateral air entry present position of trachea - centrall
Vesicular breathsounds heard
CNS : intact
ABDOMEN : Soft and non tender
No palpable masses
Bowel sounds heard
NO organomegaly
Investigations :
Dengue NS1 antigen : positive
RFT
Hemogram
Blood sugar Random
Blood grouping and RH type
ECG
Ultrasound abdomen
Day 2 (28-8-22)
Diagnosis - Dengue with thrombocytopenia
Treatment:
On day 1 (27-8-22)
1. IVF 1 unit NS , RL @ 100ml /hr
2.Tab. DOLO 650 mg PO BD SOS
3. Temperature monitoring every 4th hourly.
Discharge summery
Date of discharge:
Date: 29/8/2022
Ward:MEDICAL WARD
Unit: 6
Treating faculty:
Diagnosis:
Dengue with thrombocytopenia
A 29-year-old female patient came to the casualty with the cheif complaints of fever and vomitings since 4 days.
History of present illness :
H/o Fever-
Onset - insidious
Duration- since 4 days
Type - intermittant ,low grade
It was relieving on taking medications .
Associated with chills and rigors.
Associated with generalised body aches
Diurnal variation absent
No increased temperature at night
H/0 vomitings 4 days back
One episode
Non-blood stained, non bilious, non foul smelling
Non projectile
Content - water and food
Past history:
Not a known case of,
Hypertension, diabetes, epilepsy, CAD, asthma, thyroid.
Treatment given:
1. IVF 1 unit NS , RL @ 100ml /hr
2.Tab. DOLO 650 mg PO BD SOS
3. Temperature monitoring every 4th hourly.
Advice at discharge:
1.Tab. DOLO 650mg PO/TID for 3 days
2. Tab. PANTOP 40 mg PO/OD
3. Plenty of oral fluids.
4. Tab MVT PO/OD
Follow up:
Review GM OP after 3 days with hemogram
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
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