GENERAL MEDICINE ELOG-01 AUG-06/2021

Divya Polagoni

Roll No:01

(Old batch)

3rd semester

Under the guidance of Dr. Manasa (intern) 

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission

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 a diagnosis and treatment plan. 

CASE SCENARIO:

     A 15 yr male came to casuality  with chief complaints of high grade intermittent fever, with dengue positive (tested outside the hospital) with clear  thrombocytopenia


CHIEF COMPLAINTS:-

*Fever since -5days with high grade intermittent

*Generalized body pains positive

*Pain in abdomen -5days

*Vomiting since -2days

*No burning micturition but high coloured urine

*Black coloured stools since 2days with foul smell

History of present illness:-

*No h/o chills

*No h/o cough or cold

*No h/o diarrhoea/constipation

*MALENA positive

*No h/o bleeding manifestation

*Dengue positive (tested outside hospital)

*Thrombocytopenia +

*No other complaints


History of past illness:-

*Similar complaint in past but releived spontaneously (5 years back)

*Not a k/c/o DM/asthma/epilepsy/CAD/TB


Vitals examination and check :-

PR : 100bpm

BP:100/70mmhg

Cvs :S1S2 positive

RS:BAE+,NVBS

P/a :soft ,na

CNS:NFND

Reports of dengue tested outside:

NS1 antigen: positive

Widal test 1:80 positive

Hb :15.8

TLC:2,400

Platelet count - 41,000


GENERAL EXAMINATIONS:-

*Pallor-present 

*No-Icterus/Cyanosis/Clubbing Lymphadenopathy/Edema/Malnutrition

*Dehydration - present

*Temperature -103 C/F

*Pulse rate - 96 /min

*Bp - 130/60 mmhg

*Spo2 - 96 %

*GRBS - 126 mg%


SYSTEMIC EXAMINATION:-

CVS:  

No Thrills

Cardiac Sounds - S1, S2 +

No cardiac murmurs


RESPIRATORY SYSTEM: 

Dyspnoea - No

No Wheezing

Position of Trachea - Central

Vesicular sounds 


ABDOMEN:

*Shape - Obese

*No tenderness, palpable mass, No fluid, No bruits, 

*Bowel sounds- present

*Hernial Orifices - Normal

*Liver Spleen - Not palpable

*Genitals speculum examination, PV examination, P/R examination - Normal


CNS:

*Level of consciousness - conscious

*Speech - Normal

*No signs of meningeal irritation

*Cranial nerves - Normal


Investigation ordered :-

*Complete urine examination

*Liver function test

*Blood grouping and typing

*Serum creatinine

*Serum urea

*Serum electrolytes 

*Chest x ray

*Ecg


Investigation:-















MEDICATIONS AND REPORTS:

ON 03/08/2021


ON 04/08/2021











ON 05/08/2021:





VIEWS:

Improvement in platelet count.

Improvement and  recovery is seen in this patient.


Provisional diagnosis:

VIRAL PYREXIA THROMBOCYTOPENIA

 DENGUE


* It says there’s fluid around the spleen, liver and kidney.

* Gall bladder wall is swollen.

*He has fever and thrombocytopenia which are classical symptoms and signs of dengue

* Abdomen pain  can also occur in dengue.

*Body pains 

*The platelets were 32,000 when  he got admitted.



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