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’ve 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.
AN 38 YEAR OLD FEMALE BROUGHT TO THE HOSPITAL WITH FEVER, CHILLS AND BODY PAINS FOR 1 WEEK
CASE:
CHIEF COMPLAINTS:
A 38 year old female patient came with the complaints of fever, chills, and body pains for the past one week.
She is a resident of Mothkur, and a daily wage worker until 18 years ago, when she stopped working to work at home.
HISTORY OF PRESENT ILLNESS:
- Patient was apparently asymptomatic 1 week back when she developed fever and chills which was insidious in onset, continuous, low grade, decreasing on taking medications, had no aggravating factors and was slightly increased toward the evening.
- She also had complaints of headache and body pains for the past one week. Headache is localised in the frontal region. Not associated with nausea, vomiting, blurring of vision, photophobia.
- No peteciae and purpura seen and no other bleeding manifestations were observed.
- Patient had no burning micturution, occasionally had difficulty in passing stools and passed blood.
- No tingling sensation and numbness in the legs, no giddiness, no cough, no cold and no pain or abdominal tenderness is observed.
PAST HISTORY-
- No similar episodes in the past.
- Patient is a known case of HIV since 2005, and is on dolutegravir, lamivudine and tenofovir disoproxil fumarate tablets (50mg+300mg+300mg) for the past 12 years.
- Patient is not a known case of diabetes, hypertension, tuberculosis, epilepsy, asthma, thyroid and CAD.
- H/O tubectomy 16 years ago.
PERSONAL HISTORY-
Diet: Mixed
Appetite: Decreased for the past 1 week
Sleep: Decreased for the past 1 week
Bowel and Bladder: Regular, occasionally (every 5-6 months) she has blood in stools
No allergies
Takes alcohol/toddy occasionally (only on festivals)
FAMILY HISTORY-
No similar history in family.
GENERAL EXAMINATION
Patient is examined in a well lit room after taking informed consent.
Patient is conscious, coherent and cooperative.
She is moderately built and moderately nourished.
Pallor: Present
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Generalized Lymphadenopathy: Absent
Edema: Absent
Dehydration: Mild
VITALS
Blood Pressure: 110/70 mmHg
Respiratory Rate: 19 cycles per minute
Pulse: 108 bpm
GRBS- 107mg%
Temperature: Afebrile
SYSTEMIC EXAMINATION:
RS: BAE+
PA: SOFT, NT
CNS: NFND
INVESTIGATIONS :
23/12/22
HEMOGRAM
Hemoglobin: 11.6
TLC: 5300
Platelet: 1.50 (previous day- outside report said 9800)
MCV: 79.2
MCH: 25.4
PCV: 36.2
RBC COUNT: 4.57
ELECTROLYTES
Na: 136
Cl: 101
K: 3.6
RBS- 80
HbA1C- 6.1
RENAL FUNCTION TESTS
Urea: 30
Creatinine: 0.6
LIVER FUNCTION TESTS
Total Bilirubin: 2.48
Direct Bilirubin: 1.5
SGOT: 147
ALT: 129
ALP: 112
Total Protein: 6.7
Albumin: 3.6
A/G: 1.16
PROVISIONAL DIAGNOSIS-
Viral pyrexia under evaluation with HIV positive, with thrombocytopenia (98,000)
TREATMENT-
On 23/12/22
On admission, patient was given IV neomol
On 24/12/22
1) IVF- 10NS, 10RL @75ml/hr
2) Plenty of oral fluids
3) Tab Dolo 650mg PO TID
4) Tab Ultracet PO BD
5) Normal oral diet
Continue the normal medication schedule
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