General medicine elog 5
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 21 year
old male had come to the OPD with complaints of fever since one week ,
abdominal pain and distention since one week and loss of appetite
Chief
complaint
-fever
since 1 week
FEVER :
High grade and intermittent
-abdominal
pain and distention since 1 week
-loss of appetite
There is
presence of dry cough on supine position
-no history
of vomiting , loose stools
-no history
of headache
HISTORY OF
PRESENT ILLNESS
He got
treated in a local hospital for 4 days for fever and he was referred to KIMS
Narkatpally as his platelet count was low
HISTORY OF
PAST ILLNESS
-Not a
known case of Diabetes Mellitus, hypertension , Asthma , Epilepsy , Coronary
artery disease , Tuberculosis
TREATMENT HISTORY
-not relevant
PERSONAL HISTORY
-age : 21
-
occupation : Student
- diet :
mixed
-bowel movement:
Regular
-micturition:
Normal
-known
allergies: no known allergies
-addictions
: no known addictions
FAMILY HISTORY
-His mother
has Hypertension
GENERAL
EXAMINATION
Patient is
conscious , coherent and cooperative
Moderate build
and not malnutririoned
His body temperature
is 98.4 degree Farenheit
-Pallor : not present
-icterus : not present
-cyanosis : not present
-clubbing : not present
-lymphadenopathy : not present
-pedal edema : not present
SYSTEMIC EXAMINATION
Pulse rate : 56bpm
Blood pressure : 110/90 mmHg
Cardiovasular system :
S1 and S2 are heard
Respiratory system :
-Bilateral air entry is present , Normal vesicular breath sounds are
heard
Per Abdomen examination
-soft and NT *
Central nervous system
-NFND *
INVESTIGATIONS
-hemogram
CHEST X-RAY
PROVISIONAL DIAGNOSIS
-dengue (NS1 positive )with thrombocytopenia
TREATMENT PLAN
18/08/2021
BP, PULSE RATE , TEMPERATURE,SPO2 MONITORING
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