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

Comments

Post a Comment

Popular posts from this blog

FORMATIVE BIMONTHLY BLENDED LEARNING ASSIGNMENT.

Hi , this is G. Jagadeesh , 3rd semester student on online E-learning platform . These are pe er reviews of certain cases of deidentified data of some patients. Q-1 CASE-GASTROENTEROLOGY  https://vamsikrishnarollno16. blogspot.com The case is about the Obstructive jaundice . He is of 64 year old male . The presentation is very nice - appreciable The pictorial represention of Icterus sign in the sclera is excellent. CASE - CNS https://87tharunkumar. blogspot.com/ The case is related to Demyelinating lesion secondary to Hypertension . case presentations is very good with side headings Every Investigation reports are mentioned clearly and with appropriate Graphs and photos Which actually gives a completion to the blog and is satisfactory . Treatment is mentioned clearly with all drugs such as their routes of administrations and perfect dosage.  patient progress report daily is not mentioned. CASE-HEMATOLOGY https://mahithguduri63. blogspot.com/ It is case of pancytopenia of 70 year old ma
Read more

70M with SOB and cough

Image
Hello all this is G Jagadeesh,a eight semester student.This E Log depicts the patient centered approach to learning   This is an an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the 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 The patient/ attender was informed the purpose of the information being acquired. An infor
Read more

54M with fever and SOB

Image
Hello all this is G Jagadeesh,a eight semester student.This E Log depicts the patient centered approach to learning   This is an an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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 The patient/ attender was informed the purpose of the information being acquired. An informe
Read more