41 YEARS OLD MALE WITH PANCYTOPENIA

March 07, 2023

This is 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 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 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

M Kalpana

Roll no -92

Case history -

Date of admission-7/3/23

41 year old male who works as ward boy in the hospital came with the complaints of

-fever since 15 days

-body pains and generalised weakness since 10 days

-loss of appetite since 1week

History of illness-

Patient was apparently asymptomatic 15 days back then developed

-fever since 15 days ,low grade , not associated with chills and rigors , fever more during nights and relieved with medications. Patient went to local doctor and took medications and 2 injections.Body pains and generalised weakness since 10 days

Loss of appetite present since 1week

No history of vomitings ,loose stools,giddiness,cough ,cold,SOB,

H/O greenish color/black colored stools

H/o easy fatiguability present

No h/o pain abdomen

Past history-

N/K/C/O HTN,DM,CAD, thyroid , seizure disorder

H/O umbilical hernia surgery 2years back

H/o leucorrhea of left eye since childhood

Personal history-

Occupation-ward boy

Appetite -decreased since 1week