45 year old Male with dengue

 


This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are 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, and investigations, and come up with a diagnosis and treatment plan.

Pt came to casuality with c/o fever since 4 days 

HOPI:Pt was apparently asymptomatic 4 days back then he had fever which is of high grade continuous with chills and rigor. No SOB, chest pain, cold,cough, sore throat. No palpitations, sweating ,vomitings.h/o 15 episodes of loose stools yesterday, watery consistency,large quantity,yellow Color, non foul smelling,relieved on medication.

No burning micturition

He went to local hospital where he got tested positive for dengue NS1 Ag

Past history:

 n/k/c/o DM,HTN,TB,asthma,CVA,CAD,epilepsy.

Personal history:

Diet: mixed,Appetite: normal

Bowel and bladder:regular 

No known allergies 

Habits: occasional alcohol ( stopped 6 months back)

Family history: not significant 

General examination:

Pt is conscious,coherent, cooperative 

No pallor,cyanosis, clubbing, lymphadenopathy,edema

Bleeding manifestations:red spots over the palate

HESS test:

Vitals:

Temperature:98.4 f

PR:78 bpm

BP:110/70 mmHg 

RR:19 cpm

SpO2:98%

GRBS:116mg/dl

Systemic examination:

CVS:S1,S2 +, no murmurs 

RS:BAE+,NVBS

Abdomen: obese abdominal wall


Soft, non tender

No organomegaly 

Hernial orifices free

CNS: intact

Investigations:


 


Provisional diagnosis:

Dengue NS-1 Ag positive with thrombocytopenia 

Treatment:

1)IV fluids-NS,RL @100 ml/ hr

2)inj.NEOMOL 1 gm/ iv/sos ( if temp >101F)

3)inj.PAN 40 mg iv/od

4)tab.PCM 650 mg po/sos

5)Bp,PR,RR,temp monitoring 2nd hourly

7)report sos if any bleeding manifestations occur 



Comments

Post a Comment

Popular posts from this blog

57 year old with acute ischemic stroke

Image
This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome.  Name: M.Srilekha Admitted on 19/2/23: Chief complaints: Pt was bought to the casuality with complaints of shortness of breath weaknesses of upper and lower limbs slurring of speech difficulty in swallowing since 2:00pm today  History of presenting illness: Pt was apparently asymptotic 14years back then he developed SOB chest pain PTCA/stent replacement was done and was on regular follow up for the same  Today morning while doing his routine activities he developed
Read more

50 year old male with viral pyrexia

Image
 Mallannagari.Srilekha roll.no:77 9th semester  This is online E log book to discuss out patients de-identified health data shared after taking his guardian`s 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 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 comments box is welcome. A 50 year old male came to the opd with  Chief complaints of : fever since 3 days  Cold and cough since 3 days  History of presenting illness: The patient was apparently asymptomatic 3 days back and then he had fever which is of high grade and associated with cills and rigors  Cough since 3 days which is sudden in onset and productive with mucoid nature. Not associated with shortness of breath. Cold since 3 days. No history of chest pain, palpitations. No history
Read more

A 48 year male with viral pneumonia due to COVID

Image
 Mallannagari.Srilekha Roll No:- 77 MBBS 8th-Sem  This is online E log book to discuss out patients de-identified health data shared after taking his guardian`s 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 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 comments box is welcome.       A 48 YEAR OLD MALE WITH CHIEF COMPLAINTS OF COUGH AND SHORTNESS OF BREATH SINCE 2 DAYS  CAME TO HOSPITAL ON 17TH OF MAY    HISTORY OF PRESENT ILLNESS The patient was apparently asymptomatic 2days back , then developed cough and shortness of breath. Cough is sudden in onset, continues in nature and aggravated on sleep. Shortness of breath is present on daily activities also(GRADE 4).  Patient was tested positive for COVID on 6th may and used kit given by the
Read more