General medicine Final Practicals short case

M Kalpana

Hallticket no-1701006110

Batch -2017

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

52 years old male with fever with thrombocytopenia

Case history :

52 years old male who is farmer by occupation came to the hospital on 8/6/22 with chief complaints of 

-Fever  since 4 days

- abdominal distension since 3days

History of presenting illness:

Patient was apparently a symptomatic 4days  back then he developed fever which is low grade, continuous ,not associated with chills &rigors , no aggravating factors ,relieved with medications which was given by local RMP

He developed abdominal distension  which is insidious in onset ,progressive type ,not associated with pain

He had decreased appetite since 3days

Before admission in our hospital ,He went to government hospital where he diagnosed with thrombocytopenia (17000 cells/mm3)

No history of rashes ,bleeding tendencies

No history of headache ,vomitings, generalised body pains

No history of loose stools , pain abdomen

No history of weight loss

Past history:

No history of similar complaints in the past

No history of hypertension ,diabetes ,TB,asthma,CVA, CAD

Personal history:

Diet - mixed

Appetite- decreased 

Sleep -adequate

Bowel &bladder  movements -regular

Addictions -occasional alcoholic (90ml)& toddy

                   Toddy intake 5days back     

Family history:

No similar complaints in the family

No history of hypertension ,diabetes ,TB, asthma, cad             

General examination:

After taking consent ,patient is examined in well lit room 

Patient is conscious, coherent ,cooperative ,well oriented to time , place , person

Moderately built &moderately nourished

Pallor - absent

Icterus -absent

Cyanosis-absent

Clubbing -absent

No lymphadenopathy and edema

Vitals-

Temperature-now Afebrile but at the time of admission he is febrile.

Pulse-85 bpm

Repiratory rate-20 cpm

Bp-120/80 mmHg measured in supine position,in left upper arm .

Spo2:98%at room air

Grbs-120 mg/dl 

SYSTEMIC EXAMINATION-

Abdominal examination-

Inspection-

Shape of abdomen -round and distended

Umbilicus- inverted and central in position

No visible  scars  and sinuses

No engorged veins .

Palpation-

No local rise of temperature

No tenderness 

Inspectory findings are confirmed.

Soft and non tender ,no organomegaly , 

abdomen is distended .

PERCUSSION- dull note heard

AUSCULTATION-

Bowel sounds were heard 

No bruit.

Respiratory system-

BAE- Present

Normal vesicular breath sounds

Cardiovascular system -

S1,S2 heard ,no murmurs 

CNS: normal ,intact

PROVISIONAL DIAGNOSIS-

*Viral pyexia With thrombocytopenia 

INVESTIGATIONS-

Complete blood picture-

Hb-14.9g%

WBC-10,500 cells/mm3

Platelets-17000/mm3@outside hospital report 

On 8/06/22: 

Platelets-22000 /cumm

Neutrophils -43%

Lymphocytes -48 %

Eoisinophils -01%

Blood urea-59 mg/dl

Serum creatinine -1.6mg/dl

Serum electrolytes:

Na-142 mEq/l

K-3.9mEq/l

Cl-103 mEq/l

Liver function tests-

Total bilirubin-1.27 mg/dl

Direct bilirubin-0.44 mg/dl

SGOT-60 IU/L

SGPT-47IU/L

ALP-127IU/L

TOtal proteins- 5.9 gm/dl

Albumin-3.5g/dl

A/G ratio-1.48

COmplete urine examination-

Albumin -positive

Pus cells -4-5 

Epithelial cells -2-3

NS1 ANTIGEN - POSITIVE

SEROLOGY -IgM and IgG negative

on 9/06/22-

Hb- 14.3g%

Platelets- 30,000/cumm

On 10/06/22-

Hb-14.0 g%

Platelets-84000/cumm

USG-

IMPRESSION-

GRADE 2 FATTY LIVER 

MILD SPLENOMEGALY 

RIGHT SIDE PLEURAL EFFUSION (MILD)

MILD ASCITES 

Treatment-

*On 8/6/22

IV FLUIDS - NS AND RL@100ML/hr

Inj.pan 40 mg iv /oD 

Inj.optineuron 1 amp in 100 ml Na iv/OD over 30 mins

Inj.zofer 4 mg iv/SOS 

VITALS monitoring 4th hourly

*On 9/6/22

Iv fluids - Ns/RL @100 ml/hr

Inj.pan 40 mg iv/OD

Inj.optineuron 1 amp in 100 ml/Ns/iv/OD over 30 mins 

Inj.zofer 4mg/iv/sos 

Tab.doxycycline 100mg PO/BD 

VITALS monitoring 

*On 10/06/22;

Iv fluids - NS,RL@100 ml/hr

Inj.pan 40 mg iv/oD

Tab.doxycycline 100 mg Po/BD

Inj zofer 1 amp iv/sos

Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins 

VITALS monitoring 4 th hourly

*On 11/06/22-

Iv fluids - NS,RL@100 ml/hr

Inj.pan 40 mg iv/oD

Tab.doxycycline 100 mg Po/BD

Inj zofer 1 amp iv/sos

Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins

DOLO 650mg /sos 

VITALS monitoring