125 Afrin shaik, GM

    AFRIN SHAIK    

                           3rd sem ,roll no:125

Under the guidance of Dr. Kusuma (intern)

   This is an online e-log platform to discuss case scenario of a patient with their guardians 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. 


Date of admission : 5th July 2021

CASE SCENARIO :

 The patient 60yr old male came to casualty with c/o fever and giddiness since 3 days.

Chief complaints:

Patient came to casualty with fever (3 days .)

C/O giddiness ..(3days)

HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 3days back .

C/o fever sudden onset 3days .

No chills and rigor 

No diurnal variation 

Loss of taste .

No c/o cold and cough 

No complaints of chest pain, palpitations,syncopal attack .

No c/o for orthopnea PND.

No c/o abdominal pain , nausea,loose stools , vomitings .

No C/o burining micturation .

No c/o decreased urine output ,pedal edema ,facial puffiness .

HISTORY OF PAST ILLNESS :

No h/o Hypertension, diabetes, epilepsy, tuberculosis, asthma.

PERSONAL HISTORY :

A Non vegetarian, mixed diet.

Bowels- regular

Micturation - normal 

Addictions-

Alcohol-occasional .

FAMILY HISTORY :

 no h/o same complaints in the family.No abnormality detected. 

* GENERAL EXAMINATION :

Mild Pallor

Y is the pt pallor? 

No cyanosis ,icterus ,  clubbing,oedema, lymphadenopathy.

PR: 46bpm (bradycardia)  

BP : 100/60mm/Hg 

SpO2: 99%

GRBS_218mg%  ( less than 200 is normal)  

Reason for abnormality grbs as it is non diabetic?

* SYSTEMIC EXAMINATION :

Cardiovascular system :

 no thrills 

Cardiac sounds S1,S2+

No Cardiac murmurs . 

Palpitations seen ?

Respiratory system : 

Position of trachea -central 

No dyspnoea,wheezing .

Breath sounds - vesicular 

Abdomen: 

Obese 

Hernial orifices- normal 

Non tender, No palpable mass.

Central nervous  system :

Speech -normal 

No signs of meningeal irritation 

Motor and sensory system -normal 

Reflxes- present 

Cranial nerves - intact .

INVESTIGATIONS :

Live function test : 




Complete blood picture : 


Test :



Temperature : 
 






Provisional diagnosis: 

Dengue fever with thrombocytopenia.

Treatment :

1) IV fluids 

2)Tab.PCM 650mg PO/TID

3)inj.PCM 1g/iv/stat,if temperature is more than 101 degree F

4)inj.PAN 40mg iv/OD

5)inj.Optineuron 1amp in 100ml NS/IV/BD.

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