60M with fever

 Hello all this is G Jagadeesh,a eight semester student.This E Log depicts the patient centered approach to learning 

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’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 "

Chief complaints:

Fever since 1 day 

Cough since 1 day 

Vomiting since today morning 

HOPI 

pt was apparently asymptomatic then he developed fever which is of high grade intermittent a/w chills and rigor, vomitings

(non projectile non bilious watery filled with food particles

No c/o pain abdomen cold loose stools burning Micturition

Past history : 

N/k/c/o HTN , DM , thyroid epilepsy asthma CAD CVD

H/o pneumonia? 3 months back 

General examination 

Pt is conscious coherent cooperative 

No pallor icterus cyanosis clubbing edema lymadenopathy 

VITALS 

BP: 130/80

PR: 86/min

RR: 18/min

Temp: 99F

Spo2 : 99%

GRBS : 98mg%

Systemic examination :

   

Cvs : s1s2 heard no murmurs 

PA : soft and non tender, no organomegaly 

CNS : No focal neurological deficit

RS : BAE+ b/l crepts present in Rt IAA

Investigations: 

 

      

   

    PROVISIONAL DIAGNOSIS: 

              Viral pyrexia with thrombocytopenia 

TREATMENT: 

IV fluids NS or RL @ 100 ml /hr

Inj NEOMOL 1gm I/SOS (if temp > 101F)

Inj ZOFER 4 mg IV/SOS

Tab PCM 650 mg PO/QID

Monitor vitals 4 hrly