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 Patient's clinical
problems with collective current
evidence based inputs.
This E log also represents my
patient centered online learning
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Case Discussion :
I have been given this case to solve in an order to 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 50 year old female came to the Hospital with the chief complaints of
* Fever since 1 week
* Generalized weakness since 1 week
* Heavy menstrual bleeding 2 days ago
History of present illness :
* Patient was apparently asymptomatic 1 week ago then she developed fever which of low grade, continuous in nature , not associated with chills and relieved on medication, and is associated with generalized weakness.
* She got her menstrual bleed 10 days before and flow was high compared to previous cycles for which she went to hospital and was given medication and one day later , she went to hospital for checkup and was found to be having low platelet count and dengue NS1 reactive and was referred for further management.
* Then he had Nausea since 1 week and it is not associated with vomitings
* She had black coloured stools since yesterday evening.
History of Past Illness :
* No History of Similar Complaints in the Past.
* Not a Known Case of DM, TB , Asthma, Epilepsy, Coronary Artery Disease.
Personal history:
Diet - Mixed
Appetite - Decreased
Sleep - Adequate
Bowel movements - Regular
Bladder Movements - Regular
Addictions - None
Family History :
Not significant
Physical Examination :
A. General Examination
* Patient is conscious, coherent and co-operative and lying on the bed.
* She is well oriented to time, place and person.
* She is mildly nourished.
Pallor - Absent
Icterus - Absent
Clubbing - Absent
Cyanosis - Absent
Lymphadenopathy - Absent
Edema - Absent
VITALS AT THE TIME OF ADMISSION:
Temperature - 98.8 F
Pulse Rate - 77 BPM
Blood Pressure - 120/90 mm Hg
Respiratory Rate - 18 CPM
SPO2 - 100% at Room Air
Random Blood Sugar - 95 mg/dl
Systemic Examination :
CARDIOVASCULAR SYSTEM - S1 and S2 present, No murmurs
RESPIRATORY SYSTEM - BAE +, NVBS
PER ABDOMEN - Soft and Non tender, Scaphoid shaped abdomen ,
No free fluid ,
No palpable mass,
No organomegaly .
CENTRAL NERVOUS SYSTEM - E4V5M6, Moving all the four limbs against gravity.
Provisional Diagnosis :
Dengue NS1 positive with Thrombocytopenia
Treatment :
1. IV FLUIDS NS AND RL @ 100 ML/HR
2. INJ. NEOMOL 1GM / IV /SOS
3. INJ. PAN 40 MG /IV/ OD
4. INJ. ZOFER 4 MG / IV/ SOS
5. TAB. PCM 650 MG / PO /TID
6. WATCH FOR BLEEDING MANIFESTATIONS
7. MONITOR VITALS AND INFORM SOS
05/09/2022 :
O:
Patient is conscious,coherent and cooperative
BP - 110/80 mm Hg
PR - 84 bpm
RR- 18 cpm
Temp - Afebrila
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , non tender
CNS-NAD
I/O - 2100 / 1450 ml
A : Dengue NS1 positive with Thrombocytopenia
P :
1. IV FLUIDS NS AND RL @ 100 ml/hr
2. INJ. PANTOP 40 mg IV /OD
3. INJ. OPTINEURON 1 amp in 100 ml NS /IV/OD
4. TAB. DOLO 650 mg /PO/TID
5. INJ. NEOMOL 1 gm /IV/SOS
6. INJ. ZOFER 4 MG /IV /SOS
7. PLENTY OF ORAL FLUIDS
8. WATCH FOR BLEEDING MANIFESTATIONS AND POSTIRAL HYPOTENSION
06/09/2022 :
One episode of black coloured stools yesterday evening and one episode today morning
O:
Patient is conscious,coherent and cooperative
BP - 110/80 mm Hg
PR - 80 bpm
RR- 16 cpm
Temp - Afebrila
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , non tender
CNS-NAD
A : Dengue NS1 positive with Thrombocytopenia
P :
1. IV FLUIDS NS AND RL @ 100 ml/hr
2. INJ. PANTOP 40 mg IV /OD
3. TAB. DOLO 650 mg /PO/TID
5. INJ. NEOMOL 1 gm /IV/SOS
6. INJ. ZOFER 4 MG /IV /SOS
7. Monitor vitals and inform sos
8. WATCH FOR BLEEDING MANIFESTATIONS AND POSTIRAL HYPOTENSION
07/09/2022 :
O:
Patient is conscious,coherent and cooperative
BP - 100/80 mm Hg
PR - 80 bpm
RR- 16 cpm
Temp - Afebrile
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , non tender
CNS-NAD
A : Dengue NS1 positive with Thrombocytopenia
P :
1. IV FLUIDS NS AND RL @ 100 ml/hr
2. INJ. PANTOP 40 mg IV /OD
3. TAB. DOLO 650 mg /PO/TID
5. INJ. NEOMOL 1 gm /IV/SOS
6. INJ. ZOFER 4 MG /IV /SOS
7. Monitor vitals and inform sos
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