52 year old male with pyrexia , thrombocytopenia and ascites.
This is online E log book 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 available global online community of experts with an aim 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 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.
FINAL EXAMINATION LONG CASE REPORT:
Reg no :1701006153
Batch -2017
CASE HISTORY:
52 year old male,farmer by occupation, resident of Nalgonda came to hospital with chief complaints of:
• Fever since 6 days.
• Abdominal tightness since 6 days.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 6 days ago when he developed,
• Fever is insidious in onset, gradually progressive , low grade , continuous, no chills and rigor. No aggravating factors but relieved with medication given by rmp.
•Abdominal tightness was present since 6 days insidious in onset,not associated with pain , vomiting and diarrhoea.
• Weakness since 6 days
•History of decreased appetite since 5 days.
• He was admitted into Nalgonda hospital for 2 days before getting admitted here , he was diagnosed with thrombocytopenia (17,000cells/mm³).
•No history of headache,joint pains,body pains.
• No history of rashes and bleeding tendencies.
• No history of weight loss.
PAST HISTORY:
•No similar complaints in the past.
•No history of diabetes mellitus, hypertension, tuberculosis, asthma , cerebro vascular accident and coronary artery disease.
PERSONAL HISTORY:
Diet - Mixed.
Appetite- decreased since 5 days.
Sleep - adequate.
Bowel and bladder- regular.
Addictions: Alcohol and toddy occasionally since 15 years.
Toddy intake 5 days back.
FAMILY HISTORY:
•No similar complaints in past.
• No history of asthma , dm , htn, cva and cad.
GENERAL EXAMINATION:
•Patient is examined in well lit room after taking consent.
•Patient is conscious , coherent and cooperative , moderately built and nourished.
• Pallor - absent.
Icterus- absent.
Cyanosis-absent
Clubbing - absent.
Lymphadenopathy-absent
Edema - absent.
No pallor:
VITALS:
Pulse - 90 beats per minute, regular rythm,normal volume and character of vessel, no radio radial delay and no radio femoral delay.
Respiratory rate - 20 cycles per minute.
Temperature - afebrile.
Blood pressure - 120/80 mm hg.
Spo2 - 98%.
Grbs - 110 mg/dl.
SYSTEMIC EXAMINATION:
Abdominal examination:
INSPECTION:
abdomen shape - distended.
Flanks - full
Umbilicus - normal.
No visible scars, sinuses , striae , engorged veins.
No visible gastric peristalsis.
PALPATION:
No local rise of temperature.
No tenderness.
Abdomen distended.
Organs couldn't be palpated.
PERCUSSION:
Fluid thrill is present.
AUSCULTATION:
Normal bowel sounds heard.
No bruit.
RESPIRATORY EXAMINATION:
BAE Present.
Normal vesicular breath sounds heard.
CVS EXAMINATION:
S1 S2 Heard, no murmurs.
CNS EXAMINATION:
No neurological deficit.
INVESTIGATION:
On 8-6-22
Hemogram:
Hemoglobin - 14.9 gm/dl.
Tlc- 10,500cells/ mm³.
Neutrophils- 43%
Lymphocytes- 48%.
Eosinophils - 01%.
Platelet count - 22000 cells/ cumm.
PCV - 42.2
Blood urea-59 mg/dl
Serum creatinine -1.6mg/dl
Serum electrolytes:
Na-142 mEq/l
K-3.9mEq/l
Cl-103 mEq/l
Liver function tests-
Total bilirubin-1.27 mg/dl
Direct bilirubin-0.44 mg/dl
SGOT-60 IU/L
SGPT-47IU/L
ALP-127IU/L
Total proteins- 5.9 gm/dl
Albumin-3.5g/dl
A/G ratio-1.48
CUE:
Albumin ++
Pus cells - 4-6
Epithelial cells - 2 -3.
NS 1 ANTIGEN Test - Positive.
IgM and IgG - Negative.
HIV RAPID TEST non reactive.
HBsAg Rapid test - negative.
Anti HCV antibodies - non reactive.
USG REPORT:
Mild splenomegaly .
Right sided mild pleural effusion.
Mild ascites.
Grade 2 fatty liver.
Gall bladder wall edematous.
On 9-6-22:
Hemogram:
Hemoglobin: 14.3gm/dl.
Wbc - 8200 cells/cumm
Neutrophils - 38%
Lymphocytes-51%.
Platelet count - 30,000/cumm.
PCV - 42.0
On 10-6-22
Hemogram:
Hemoglobin- 14 gm/ dl
Tlc - 5680cells/cumm.
Neutrophils -35%
Lymphocytes - 54%.
Platelet count-84,000/cumm.
Serum creatinine- 1.2 mg/dl.
On 11-6-22
Hemogram:
Wbc- 4800 cells/cumm.
Neutrophils - 40%
Lymphocytes-48%
Platelet count -60,000cells/cumm.
On 11-6-22 evening
Platelet count -76000cell/cumm.
On 12-6-22
Hemogram
Hb-15.3
Wbc - 7,100.
Neutrophils - 40%
Lympocytes -50%
Platelet count- 1 lakhcells/cumm.
PCV - 44.6
PROVISIONAL DIAGNOSIS:
Viral pyrexia with thrombocytopenia secondary to dengue NS1 POSITIVE with polyserositis (with right sided pleural effusion with mild ascites).
TREATMENT:
On 8-6-22
Ivf NS/RL/DNS continuous at 100ml/hr
Inj. PAN 40mg IV BD
inj. ZOFER 4mg IV/SOS
Inj. NEOMOL 1gm IV/SOS
Tab. PCM 650 mg PO/ SOS
Inj. OPTINEURON 1 AMP in 100ml NS IV/OD over 30mins.
On 9-6-22
Treatment
Iv fluids - Ns/RL @100 ml/hr
Inj.pan 40 mg iv/OD
Inj.optineuron 1 amp in 100 ml/Ns/iv/OD over 30 mins
Inj.zofer 4mg/iv/sos
Tab.doxycycline 100mg PO/BD
VITALS monitoring
On 10-6-22
Iv fluids - NS,RL@100 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 4mg iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
VITALS monitoring 4 th hourly.
On 11-6-22
Iv fluids - NS,RL@100 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 4mg iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
DOLO 650mg /sos
VITALS monitoring.
On 12-6-22
Iv fluids - NS,RL@50 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 4mg iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
DOLO 650mg /sos
VITALS monitoring.
On 13-6-22
Oral fluid
Tab.dolo650mg/po/sos.
Tab.pan 10mg/po/od.
Tab.doxycycline 100mg/po/bd.
Tab.zincovit po/od
Vitals monitoring.
Comments
Post a Comment