general medicine case 5

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 21 years old lady presented to emergency with a complaint of fever from past 5 days.

History of present illness:

Patient was apparently asymptomatic 1 week ago and had attack of fever with chills and rigors 5 days ago.the fever got subsided with the used to medication.Patient is pregnant and is in her 2nd trimester.

History of past illness:

Patient gives no history of diabetes, hypertension, epilepsy, pulmonary koch,asthma.

Patient had her 1st baby deliver done 9 months back and had c-section done to have the baby delivery.

Personal history:

Patient is does not eat properly.

Mixed diet

Bowel and bladder movement are regular

Sleep pattern is normal

Not history of addictions

Family history: 

No member of the family complians of similar clinical resemblance.

Treatment history: 

Not allergic to any known drug.

General examination:

Patient was conscious,coherent,cooperative poorly built and improperly nourished.

No signs of pallor,icterus,clubbing,cyanosis, lymphadenopathy,oedema of the feet and hand.

Vitals

Temperature:afebrile

B.P.:110/90 mm of Hg

Respiratory rate:18cpm

Pulse rate:110bpm

 CVS:

 S1 and S2 sounds are heard

Respiratory system:

NVBS+

BAE+

Abdomen:

Non tender

No palpable masses

No bruits

No hernial openings

Spleen non palpable 

Liver non palpable

Provisional diagnosis: 

Dengue fever?

Investigations:

Hemogram

Hemoglobin - 13.8 gm/dl

Total count - 4900 cell/cumm

Neutrophils - 60%

Lymphocytes - 34%

Eosinophils - 1%

Monocytes - 5%

Basophils - 0%

PCV - 39.4 vol%

MCV - 81.4 fl

MCH - 28.1 pg

MCHC - 34.5 %

RDW- CV - 14.4%

RDW-SD - 41.0 fl

RBC count - 4.84 million/cumm

Platelet count - 40000/cumm

Smear

RBC - Normocytic normochromic

WBC - Within the normal limits

Platelets - Reduced on smear

Hemoparasites - No hemoparasites detected

Impression - Normocytic normochromic blood picture with thrombocytopenia.

Diagnosis:

 Dengue fever

Treatment:

1. IVF NS }100ml/hr

           RL }

2.INJ Neomol 1gm/IV

3.Tab. Dolo 650 mg PO TID

4.Tab. Pan 40 mg PO OD

5.Tab. Doxinate 1 tab PO OD

6.Tab. Fantastic-S PO OD

7.Tab. Calforte-D3 PO HS

8. GRBS 12th hourly

9.BP. PR. TEMP 4th hourly

10.Tab Onden 4mg/PO/BD.