general medicine case report - 6

 Anahita behara 

roll no 08

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

 A 34 year old female patient had come to the OPD with history of fever since 4 days 

CHIEF COMPLAINT

-she had fever since 4 days

-she also experienced giddiness since the past 4 days 

HISTORY OF PRESENT ILLNESS

The patient was apparently asymptomatic 4 days ago , then developed fever that was high grade , with chills and giddiness  . Then they went to a local hospital were her platelet count was found to be decreased and she was referred to KIMS for further evaluation. She was admitted on 22nd August 2021 

no h/o of vomitings , loose stools and pain in abdomen 

no h/o of  severe headache , pain behind eyes , myalgia (body pains )

no  h/o of skin rashes after onset of fever

HISTORY OF PAST ILLNESS 

N/k/c/o hypertension , diabetes mellitus , thyroid disease , tuberculosis 

PERSONAL HISTORY

-age : 34

- diet : mixed

-bowel movement: Regular

-micturition: Normal

-known allergies: no known allergies

-addictions : no known addictions

FAMILY HISTORY 

not relevant 

GENERAL EXAMINATION 

-pallor ; Not present 

-icterus ; not present 

-cyanosis; not present 

-clubbing ; not present 

-lymphadenopathy ; not present 

-pedal oedema ; not present 

-malnutrition ; not present  

-dehydration ; not present 

-temperature ; afebrile 

-pulse rate ; 100/min

-respiratory count ; 22/min

-BP ; 120/80

-SPO2 at room air ; 98 % 

GRBS (general random blood sugar) ; 141 mg%

SYSTEMIC EXAMINATION 

-CVS-

-S1 and S2 heard

-RESPIARTORY SYSTEM-

-bilateral air entry is seen , normal vesicular breath sounds are heard

-ABDOMEN-

-shape of abdomen : scaphoid 

-soft and no tenderness is present

-CENTRAL NERVOUS SYSTEM-

-Level of consciousness : conscious 

-speech : normal

-no signs of meningeal irritation 

-REFLEXES-

Biceps ; right and left  : normal 

triceps ; right and left : normal

supinator ; right and left  : normal 

knee ; right and left : normal 

ankle ; right and left : normal

-GAIT- 

normal

DIAGNOSTIC TESTS 

ultra sound report











ecg




hemogram ; 22nd August 2021

fever chart

PROVISIONAL DIAGNOSIS 

-Viral pyrexia along with thrombocytopenia suspected Dengue (?)

TREATMENT PLAN 


this is an ongoing case and details will be updated 

this elog was done with the help of Dr.Achal (2016)

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