GENERAL MEDICINE - blog 2

A 39 year old male , farmer by occupation presented with fever , chills, headache & body pains 

Hi, I am Mucha Sainath Reddy  , 3rd Sem Medical Student.This is an online E log book to discuss our patient's 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 available global online community of experts with an aim to solve those patient's 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 the comment box is welcome.”


I've 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. 

CHEIF COMPLAINTS:

Complaints of fever and chills generalised body pains and headache since 4 days . No complaints of hematuria , melena or other manifestations.

DURATION :

Patients was asymptomatic 4 days back then he developed fever associated with chills which was relieved on medication where he took from local hospital. Since today morning he has complaints of bloating sensation .

HISTORY OF PRESENT ILLNESS:

In stomach 3-4 episodes of loose stools for which he went to hospital and had undergone investigations where he was found to have Igm antibodies positive for dengue he also had a low platelet count of 14,000 from there he was referred to our hospital.

HISTORY OF PAST ILLNESS:

H/O Dengue and was admitted in hospital managed conservatively 9 years back.

TREATMENT HISTORY:

No hypertension 
No DM
No CAD
No TB
No Epilepsy 
No Thyroid Disorders
No Asthma
Not taken any antibiotics previously 
No Hormonal history 
No history of blood transfusion 
No history  of surgery 

PERSONAL HISTORY :

Married
Occupation- Farmer
Appetite - Normal 
Non-veg 
Bowels-Regular 
Micturition - Abnormal 
Known allergies - No
Habits:
Alcohol- teetotaler
Drug use - no
No Tobacco 

FAMILY HISTORY :

No Diabetes
No Hypertension 
No Heart disease 
No Stroke
No Cancers
No Tuberculosis 
No Asthma

GENERAL EXAMINATION:

No pallor
No icterus
No cyanosis 
No clubbing of fingers 
No lymphadenopathy 
No Oedema of feet 
No malnutrition
No Dehydration 
Temperature 98.6 degree 
Pulse rate 86/min
Respiration - 16 / min
Bp 110/70
SPO2 at room air 98% at RA litres of O2
GRBS - 102 mg%

SYSTEMIC EXAMINATION:

CARDIO VASCULAR SYSTEM :

No Thrills
No  cardiac sounds s1,s2
No cardiac murmurs

RESPIRATORY SYSTEM:

No Dyspnoea
No wheeze
Position of trachea - central
Breath sounds - vesicular

ABDOMEN:

Shape of abdomen - scaphoid
Tenderness - Not
palpable mass - no
Hernial orifices - Normal 
Free Fluid - No
Bruits - No
Liver - Not palpable
Spleen - Not Palpable
Bowel sounds - yes

CENTRAL NERVOUS SYSTEM:

Conscious
Normal speech
No neck stiffness
No kernings sign
Cranial nerves , motor system , sensory system , Glasgow scale - Normal 

Reflexes :

Right : biceps , triceps , supinator , knee , ankle - {++}
Left   : biceps , triceps , supinator , knee , ankle - {++}

CEREBRAL SIGNS : 

Finger-nose in coordination - No
Knee heel in coordination - No

Normal Gait 

PROVISIONAL DIAGNOSIS : 

DENGUE { THROMBOCYTOPENIA }














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