SUPRIYA GAGIREDDY 42
Hi,I am supriya 8th sem medical student.This is an online elog book to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent.Here we discuss our individual patients 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 reflects my patient centered online learning portfolia
CHEIF COMPLAINTS:
28 years male autodriver by occupation admitted in hospital with c/o fever since 5 days
HOPI:
patient was apparently asymptomatic 5 days back then he developed intermittent low grade fever a/w generalised body pains, headache, and giddiness. Lots of appetite, not a/w chills and rigor no diurnal variation
No history of malena, hematuria
No complaints of chest, pain, cough, cold
No complaints of burning micturition
No complaints of loose stools, nausea, vomiting
PAST HISTORY :
Not a known case of hypertension, diabetes, thyroid, CAD CVA TB
PERSONAL HISTORY:
Appetite: normal
Diet: mixed
Addictions: no
Sleep: adequate
bowel regular
General examination:
Pt is conscious, coherent, cooperative
No signs of clubbing, cyanosis, pallor ,icterus,lymphendenopathy
Vitals :
Bp :120/90mm hg
PR:78bpm
Temp:97.8
RR: 21 cpm
Systemic examination:
Per Abdomen:
Shape of abdomen-distended
Umbilicus -inverted
Abdomen moves accordingly with respiration.
No sinuses/scars
Abdomen is soft,diffused tenderness
No free fluid
Hernial orifices-Normal
No organomegaly
Bowel sounds- present
Cardiovascular system:
Inspection-
Shape of chest-Normal
No precordial bulge.
No dialated veins,scars and discharging sinuses.
No visible pulsations.
Palpation-
Apical beat felt in 5th intercostal space.
No parasternal heave and thrills
Respiratory system:
-Inspection:
Trachea -appears to be central
Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.
elliptical in shape.
No chest wall defects.
No scars and sinuses.
-Palpation:
All the inspectory findings are confirmed.
Trachea central
Tactile vocal
Fremitus Right Left
Supraclavicular N N
Infraclavicular N N
Mammary N N
Inframammary N N
Axillary N N
Infraaxillary N N
Suprascapular N N
Infrascapular N N
-Percussion Right Left
Supraclavicular R R
Infraclavicular R R
Mammary R R
Inframammary R R
Axillary R R
Infraaxillary R R
Suprascapular R R
Infrascapular R R
R-Resonant
Auscultation Right left
Supraclavicular NVBS NVBS
Infraclavicular NVBS NVBS
Mammary NVBS NVBS
Inframammary NVBS NVBS
Axillary NVBS NVBS
Infraaxillary NVBS NVBS
Suprascapular NVBS NVBS
Infrascapular NVBS NVBS
Central Nervous system:
Conscious
Cranial nervers -normal
Tone Rt Lf
UL N N
LL N N
Power Rt Lf
Fine touch Rt Lf
Reflexes. Rt. Lt
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
PROVISIONAL DIAGNOSIS :DENGUE FEVER (NS1 &IGM POSITIVE)
Investigations:
Hemogram | 21/10/23 | 22/10/23 | 23/10/23 | 24/10/23 | 25/10/23 |
Hb | 19.1 | 17.5 | 16.8 | 15.6 | 15.2 |
TLC | 4000 | 4000 | 5200 | 5600 | 5600 |
RBC COUNT | 6.19 | 5.81 | 5.81 | 5.37 | 5.22 |
PLATELET COUNT | 18000 | 40000 | 20000 | 28000 | 52000 |
Hemogram
21/10/23
22/10/23
23/10/23
24/10/23
25/10/23
Hb
19.1
17.5
16.8
15.6
15.2
TLC
4000
4000
5200
5600
5600
RBC COUNT
6.19
5.81
5.81
5.37
5.22
PLATELET COUNT
18000
40000
20000
28000
52000
ECG
Color doppler
TREATMENT:
S/P ONE SDP TRANSFUSION ON 23/10/23
1. IV FLUIDS @75 ML/HR
2.INJ TRAMADOL 1AMPULE IN 100 ML NS IV
3.TAB PCM 650MG PO/SOS
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