A 31 year old male with complaints of Giddiness and fever.

This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING!

This is an ongoing case. I am in the process of updating and editing this ELOG as and when required. 

A 31 year old male came to casuality with complaints of Giddiness and fever since 3 days and in view of decreased platelet count of 17000/cubic mm,known in the local hospital nearby. 

History of present illness- 

He was apparently asymptomatic 3 days back ,then he developed fever,generalized weakness and Giddiness.

The fever was of high grade, associated with chills and rigor , not associated with cold,cough and headache.

Fever is associated with generalized weakness and Giddiness which was increased with walking.

No history of hematuria,melena and petechiae 

Patient was referred to our hospital in view of decreasing trends of platelet counts(60,000-45000-17000) 

Past history- 

5 months back , he suddenly developed weakness and was incoherent and asking his family who are you when they spoke to him,so was taken to a local  hospital where 1 unit of blood is transfused and patient was alright. 

Not a known case of hypertension, diabetes,tuberculosis, epilepsy,cardiovascular accident 

Personal history- 

Diet-mixed 

Appetite-lost since 3 days 

Bowel and bladder- regular 

Addictions- Regular alcohol drinker,

Tobacco smoker . 

Family history-Not significant. 

Vitals- 

Temperature- 99.7°F 

Pulse rate-87 bpm 

RR-16/min 

Bp- supine 100/60 mm hg 

     standing-90/60 mm hg 

Systemic Examination-

CVS- 

s1,s 2 heard 

No added sounds 

Resp- BAE + 

  NVBS heard 

Cns-nad 

Provisional diagnosis- Dengue fever with thrombocytopenia, with ? Alcoholic hepatitis.

Treatment given-  

IV fluids-NS,RL @ 150 ml/hr 












Comments

Post a Comment

Popular posts from this blog

A 50 year old female with fever and cough

Image
MEDICINE CASE  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 inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome A 50 YEAR OLD FEMALE WITH FEVER AND COUGH. A 50 year old female came to the casuality with chief complaints of fever and cough since 5 days. History of present illness- Patient was apparently asymptomatic 5 days back,then she developed fever which is of high grade,associated with chills and decreased on taking medication.She has cough since 5 days,which is non productive associated with sob grade 3-4 at rest.No history of cold,pedal oedema,decreased urine output,abdominal
Read more

A 40 year old male with fever and pain abdomen

Image
MEDICINE CASE DISCUSSION 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 inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. A 40 YEAR OLD MALE WITH PAIN ABDOMEN AND FEVER A 40 year old male came to casuality with chief complaints of pain abdomen and fever since 10 days. History of present illness- Patient was apparently asymptomatic 10 days ago,then he developed pain abdomen since 10 days which is in right upper quadrant,which is gradual ,progressive , pricking type,increased with movement,relieved with medications. History of fever since 10 days ,which is low grade,intermittent,not
Read more

August 2021 bimonthly blended assessment

August 21,2021 August 2021 bimonthly blended assessment 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. MONTHLY SUMMATIVE ASSESSMENT I have been given the following questions to answer in an attmept 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 diagnosis and come up with a treatment, to assess the quality of treatment given and to suggest improvisations.  The below is the link to get question paper. http://medicinedepartment.blogspot.com/2021/08/medicine-paper-for-aug-2021-bimonthly.html Q1) (Testing pe
Read more