General medicine e log

 This is 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.

A 35 year male auto driver by occupation came to opd on 16th june with chief complaints of

fever since 15 days

vomiting since 10 days

History of presenting illness:-

Patient was apparently asymptomatic 15 days ago then he developed fever which is continuous associated with back pain, no chills and rigors.

For this he visited local RMP and took medications by which fever got resolved

5 days later he developed vomitings, 6 to 7 times a day, non bilious, non projectile, food particles as contents, non bloody

This time patient went to a hospital and he was diagnosed with dengue fever and pulmonary oedema?

Past history:

No history of similar complaints

No history of any blood transfusions

N/k/c/o DM, HTN, CVD, Asthama, Epilepsy, Thyroid problems

Personal history:

Mixed diet

Adequate sleep

Normal bowel and bladder movements

No addictions

No allergies

Family history: Not significant

General examination:

Patient is conscious, coherent and cooperative, well oriented to time, place and person

Vitals:

Pulse: 72beats /mim

Bp: 124/80mm of Hg

Temperature: afebrile

RR: 16cycles/min

Systemic examination:

CVS- S1 S2 heard no murmurs

CNS- No focal neurological deficit

RS- Normal vesicular sounds heard

Provisional diagnosis:

Fever with thrombocytopenia Dengue?

Investigations

Treatment

15 /6/23

Rx

1)IV fluids Ns 75ml /hr

2)Inj zofer 4mg iv/tid

3)tab udiliv 300 mg 

4)inj optineuron 10 mp 1 ONS/iv

5)syp hepamerz 10 mL iv 

6. tab dolo 650 mg sos

16/6/23

Rx

1)IV fluids Ns 75ml /hr

2)Inj zofer 4mg iv/tid

3)tab udiliv 300 mg 

4)inj optineuron 10 mp 1 ONS/iv

5)syp hepamerz 10 mL iv 

6. tab dolo 650 mg sos

17/6/23

Rx

1)IV fluids Ns 75ml /hr

2)Inj zofer 4mg iv/tid

3)tab odiliv 300 mg 

4)inj optineuron 10 mp 1 ONS/iv

5)inj doxy 100mg po/BD

6. tab dolo 650 mg sos

7. syp hepamerz 10 mL iv 

8. Syp lactulose 15 mL bd 

18/6/23

Rx

1)IV fluids Ns 75ml /hr

2)Inj zofer 4mg iv/tid

3)tab odiliv 300 mg 

4)inj optineuron 10 mp 1 ONS/iv

5)inj doxy 100mg po/BD

6. tab dolo 650 mg sos

7. syp hepamerz 10 mL iv 

8. Syp lactulose 15 mL bd 

19/6/23

Rx

1)IV fluids Ns 75ml /hr

2)Inj zofer 4mg iv/tid

3)tab odiliv 300 mg 

4)inj optineuron 10 mp 1 ONS/iv

5)inj doxy 100mg po/BD

6. tab dolo 650 mg sos

7. syp hepamerz 10 mL iv 

8. Syp lactulose 15 mL bd