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.
Kota Hrithik Raj
Roll no 76
3/01/23
60 year old female patient who is a resident of pallipadu came with chief complaints of
•Fever since 10 days
•Generalised weakness since 10 days
•Backache since 10 days
History of presenting illness:
Patient was apparently asymptomatic 10 days back and then she developed high grade fever,sudden in onset, with chills and rigors , continuous,no evening rise of temperature
Patient complains of backache since 10 days , continuous which is insidious in onset ,dull aching type,non radiating,with no aggravating and relieving factors.
She also has complaints of body pains since 10 days for which she got medication from their local RMP but it is not subsided
As the symptoms didn't subside she went to a government hospital where she was diagnosed with low blood pressure and Decreased platelet and kept under observation.
As her condition doesnt improved she came to our hospital
Past History:
Patient has no similar complaints in the past
No surgeries underwent into the past
Not a known case of Diabetes mellitus, hypertension, coronary artery diesease,asthma, epilepsy, tuberculosis.
Personal History:
Patient takes mixed diet,
appetite is decreased,
Bladder and bowel movement are normal
Addictions: Patient consumes alcohol occasionally (1-2pegs).
Patient smokes chutta since 40 years 1-2 per day.
Patient has no known allergies
Family History:
No significant family History
Treatment History:
Antipyretics , Antibiotics (unknown)
General Examination
Patient is conscious coherent coopertive well built and well nourished.
Vitals:
Temperature: afebrile
BP- 90/70 mmHg
Pulse-80 beats per minute
RR- 15 cpm
Pallor- present
Icterus :Absent
Cyanosis- absent
Lymphadenopathy-absent
Clubbing-absent
Generalised edema- absent
Bilateral pedal edema - seen
Abdominal Examination -
On Inspection:
Abdominal Distension is present
Umbilcus is at centre (slit like)
No dilated veins
No scars,sinuses.
Palpation:
No local rise in temperature
Tenderness is elicited in the Right Hypochondrium .
No visible pulsations
No organomegaly
Percussion: No Significant Findings
Auscultation:
Bowel sounds heard
Cardiovascular system:
S1 S2 heard ,no murmurs
Respiratory system:
Bilateral Air entry present
Normal vesicular breath sounds heard
Central Nervous system:
Higher mental function intact
No focal neurological deficit
Provisional Diagnosis:
Dengue shock syndrome with Thrombocytopenia , Acute Kidney injury ,Acute Liver injury.
Investigations:
Fever chart
Hemogram:
Dengue test:
Liver function tests:
1/1/23
2/1/23
Serum electrolytes:
1/1/23
3/1/23
Serum creatinine:
1/1/23
2/1/23
Blood urea:
1/1/23
2/1/23
Treatment:IV fluids -Normal saline with 1 ampoule of optineuron
-Injection Noradr 2 ampoules in 46 ml NS
Inj PAN 40mgIV/OD
Tab PCM PO/TID
Inj Neomol .
SOAP Notes On 03/01/2023
S -
Decreased appetite
No fever spikes
Stools passed
O-
Pulse - 96 bpm
BP - 80/50 mmhg on norad 4ml/hr
RR - 32cpm
SPO2- 97 % AT RA
TEMP - AFEBRILE
CVS - S1 , S2 +
RS - BAE + , NVBS
PA - SOFT , NT.
NO ORGANOMEGALY
CNS - NAD
INPUT - 4850
OUTPUT-4300
HAEMOGRAM:
Hb – 9.7 gm/dl
TLC – 6700cells/cu mm
PLC - 16000
RENAL FUNCTION TESTS :
Sodium : 140 mEq/L
Potassium : 6.6 mEq/L
Chloride : 105mEq/L
A-
DENGUE SHOCK SYNDROME WITH THROMBOCYTOPENIA WITH AKI ( PRE RENAL -NON OLIGURIC) WITH ACUTE LIVER INJURY
P-
IVF - 1 NS With 1 Ampoule of optineuron 100 ml/hr
IVF Normal saline ,ringers lactate@ 150 ml /hour
Inj Noradr -2 ampoules in 46 ml NS @4 ml/hr
Inj Lasix 20 mg IV OD ( IF SBP >110 mmhg)
Tab Doxy 100 mg PO/BD
Monitor vitals 4th hrly
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