30 yr male

-
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 CASE OF 30 YEAR OLD MALE PATIENT 

 

A 30 year old male patient came with the chief complaints of

Complaints of fever, body pains, neck pain since 3 days. H/o dark coloured stools since 2 days.


History of presenting illness:

Patient was apparently asymptomatic 1 week ago following which patient develop fever high-grade associated with chills and headache for which he went to a local RMP doctor and there medications were given and he was sent back home but the fever did not relieve and so he went to nalgonda hospital where investigations were done and patient was found to be positive and medications were given and was put on NS IV for due to money issues he went back home. He was fine that night and the fever recurred the next day and so he came to kims on 3/12/21.

H/O three episodes of dark coloured loose stools, vomiting 1 episode that morning which was non bilious, non projectile and food particles as content.


History of past illness:

Not a k/c/o DM, HTN, TB, BA, CAD, CVA.


Personal history:

Occupation: farmer

Diet: Mixed

Appetite: normal

Sleep: adequate 

Bladder: burning micturition+

Addictions: occasionally drinks beer.


Physical examination:

Patient C/C/C

No signs of pallor, icterus, clubbing, cyanosis, edema, lymphadenopathy.


Vitals:

Temperature: afebrile

BP: 110/70 mmhg

PR: 78bpm

RR: 16cpm

Spo2: 98%.


Systemic examination:

CVS: S1 and S2 heard

RS: bae+ 

P/A: soft, non tender.

CNS: NAD.


Investigations:

Cbp on 3/12/ 21 
Hb- 17
TLC- 4600
Plt. Count- 46000
RBS- 148
Rft:
Urea- 45
Sr. Cr- 1.2
Na+: 140
K+ : 3.7
Cl- : 97
Lft:
TB-0.8
SGOT-48
SGPT-29


BGT- AB+


Cbp on 4/12/21
Hb- 15.7
TLC- 6500
Plt. Count- 13000

Transfusion done on 4/12/21
Cbp on 5/12/21, 12:30am
Hb- 14.0
TLC- 7800
Plt. Count- 60,000

Cbp on 5/12/21, 9:55 am
Hb- 14.4
TLC- 8500
Plt count- 38,000.

Diagnosis:
Dengue fever (NS1 positive)with thrombocytopenia.

Treatment:
1) Plenty of oral fluids 
2) IVF NS and RL at 150 ml/hr
3) T. PAN 40 MG PO OD
4) T. PCM 650MG PO TID
5) ORS sachets in 1 liter water. Drink 200 after each loose stool
6) INJ. OPTINEURON 1 AMP IN 100 ML NS IV OD
7) INJ. ZOFER 4 MG IV SOS
8) T. SPOROLAC DS PO TID
9) BP/PR/ Temp charting 4th hourly
10) strict I/o charting







Comments

Post a Comment

Popular posts from this blog

PARAPARESIS OF THE LOWER LIMBS SECONDARY TO TB

-
Paraparesis of the lower limbs. Hello all, I am P.Vihar (Roll no 127) a student of 8th semester pursuing medicine at KIMS Narketpalli. Today I share, in this blog  my views and thoughts on a case   which our department of general medicine has shared, to help us achieve better understanding of the clinical cases. The link given below, is to the entire case details :- https://vaish7.blogspot.com/2020/05/medicine.html?m=1 MY VIEWS AND THOUGHTS ON THIS CASE. Here we see a 23 year old male patient with history of a sudden fall when he tried to get up to use the bathroom. Patient came to the hospital in this regard complaining of weakness in both lower limbs. After going through his history i have some questions in mind which i will write down below:- 1) His chief complaint was tingling and numbness in both lower limbs since 5 days. This makes me think of paresthesia in his legs, but when we talk about paresthesia there are many causes like herniated disc, tumor in the spinal cord, etc.. al
Read more

2023 (November) JRCPTB QIP Project Cycle - 3 Presentation.

-
Image
Inpatient care Quality Improvement Project.   The Inpatient care quality improvement cycle started with the goal of improving patient care by identifying lapses, and checking progress in 4 domains of clinical practice that impact the quality of inpatient care namely;    ·        History taking  ·        Clinical/ physical examination ·        Lab and imaging data analysis ·        Full case analysis   Using the online learning portfolios of the students of 2016 batch; which was divided into 4 quarters; these 4 domains were graded based on performance from 0-4. I collected this raw data and processed the data to represent it statistically (quarter mean and cumulative mean scores). Thus enabling us to check for progress/ changes in specific domains and overall clinical practice.   After processing the data, I systematically entered the data into an excel spreadsheet and made relevant tables/ graphs to represent our findings.  These online learning portfolios were selected for cycle 3. T
Read more

80 yr male

-
 80 yrs old Male came to casualty with  C/O loss of consciousness (for half an hour) C/O involuntary bowel and bladder incontinence and slurred speech since 4am today(19/12/21) HOPI Patient was apparently asymptomatic till 4:00am today got up from bed and walked to washroom ,while walking near the door at 4:00am,patient slipped and fell on the ground-sustained injury to back and head. He had loss of consciousness for half an hour and then regained.Conscious spontaneous with no involuntary movements,froth from mouth. H/O involuntary micturition and defecation present  H/O slurred speech present after fall On presentation patient is conscious,confused,slurred speech present. Past history  N/K/C/O HTN,DM,TB,epilepsy,CVA,CAD Personal history  Diet -mixed Appetite-normal Bowel movements-irregular  He is a toddy drinker and smokes chutta  Family history  Not significant  General examination  Pt is conscious  Vitals Temp-Afebrile  Bp-120/60mmHg PR-90bpm Spo2-99% on RA Systemic examination  CV
Read more