FINAL PRACTICAL EXAM SHORT 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 inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

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 diagnosis and treatment plan.

ROLL NO: 1701006162

A 52 year old male, resident of Nalgonda, farmer by occupation, came to hospital with

CHIEF COMPLAINTS:

Fever and abdominal tightness since 6 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 6 days ago when he developed,

1.Fever- insidious in onset and gradually progressing, low grade and continuous, not associated with chills and rigor. No aggravating factor and  relieved with medication given by local rmp doctor.

2.Abdominal tightness-  insidious in onset,not associated with pain ,vomiting and diarrhoea. He also complaints of weakness since 6 days and decreased appetite since 5 days. 

He was admitted into Nalgonda hospital for 2 days before getting admitted here he was diagnosed with thrombocytopenia with 17,000cells/mm³

No history of headache,joint pains,body pains.No history of rashes and bleeding tendencies.No history of weight loss.

PAST HISTORY:

No similar complaints in the past.

No history of diabetes mellitus, hypertension, tuberculosis, asthma and epilepsy 

PERSONAL HISTORY:

1. Diet - Mixed.
2. Appetite- decreased since 5 days.
3. Sleep - adequate.
4. Bowel and bladder- regular.
5. Addictions: consumes Alcohol and toddy since 15 years.(consumed toddy i 5 days back)

FAMILY HISTORY:

No similar complaints in past.

No history of asthma, Diabetes mellitus, Hypertension and epilepsy.

GENERAL EXAMINATION:

Patient was examined in a well lit room after taking informed consent. He is conscious, coherent and cooperative; moderately built and well nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.

VITALS:

1. Pulse - 90 beats per minutee
2. Respiratory rate - 20 cycles per minute.
3. Temperature - afebrile.
4. Blood pressure - 120/80 mmHg.
5. Spo2 - 98%.
6. GRBS - 110 mg/dl.

No pallor

Left eye:

Right eye:

SYSTEMIC EXAMINATION:

1. ABDOMINAL EXAMINATION:

• INSPECTION:

1. Abdomen shape - distended
2. Flanks full
3. Umbilicus - normal
4. No visible scars, sinuses , striae , engorged veins.
5. No visible gastric peristalsis.

• PALPATION:

1. No local rise of temperature.
2. No tenderness.
3. Abdomen distended.
4. Organs not palpable

• PERCUSSION: Fluid thrill is present.
  
  
• AUSCULTATION: 

1. Normal bowel sounds heard.
2. No bruit.

   2. RESPIRATORY EXAMINATION:

• BAE Present.
• Normal vesicular breath sounds heard.

   3.CVS EXAMINATION: S1 S2 Heard, no           murmurs.

   4.CNS EXAMINATION: No neurological deficit.

INVESTIGATION:

8/06/2022

1. Hemogram:

• Hemoglobin - 14.9 gm/dl.
• Total leucocyte count- 10,500cells/ mm³.
• Neutrophils- 43%
• Lymphocytes- 48%.
• Eosinophils - 01%.
• Platelet count - 22000 cells/ cumm.
• PCV - 42.2

   2.Blood urea-59 mg/dl

   3.Serum creatinine -1.6mg/dl

   4.Serum electrolytes:

• Na:142 mEq/l
• K:3.9mEq/l
• Cl:103 mEq/l

  5.Liver function tests-

• Total bilirubin-1.27 mg/dl
• Direct bilirubin-0.44 mg/dl
• AST-60 IU/L
• ALT-47 IU/L
• ALP-127IU/L
• Total proteins- 5.9 gm/dl
• Albumin-3.5g/dl
• A/G ratio-1.48

   6.COMPLETE URINE EXAMINATION:

• Albumin ++
• Pus cells - 4-6
• Epithelial cells - 2 -3.
• NS1 ANTIGEN Test - Positive.
• IgM and IgG - Negative.

  7.HIV RAPID TEST non reactive.

  8.HBsAg Rapid test - negative.

  9.Anti HCV antibodies - non reactive.

 10.  Ultrasound: interpretation

•  Mild splenomegaly .
• On right side mild pleural effusion.
• Mild ascites.
• Grade 2 fatty liver.
• Gall bladder wall - edematous.

  9/06/2022

Hemogram:

• Hemoglobin: 14.3gm/dl.
• Wbc - 8200 cells/cumm
• Neutrophils - 38%
• Lymphocytes-51%.
• Platelet count - 30,000/cumm.
• PCV - 42.0

10/06/2022

1Hemogram:

• Hemoglobin- 14 gm/ dl 
• Tlc - 5680cells/cumm.
• Neutrophils -35%
• Lymphocytes - 54%.
• Platelet count-84,000/cumm.

2.Serum creatinine- 1.2 mg/dl.

11/06/2022

1.Hemogram:

• Wbc- 4800 cells/cumm.
• Neutrophils - 40%
• Lymphocytes-48%
• Platelet count -60,000cells/cumm
• Platelet count -76000cell/cumm.(Same day evening)

12/06/2022

Hemogram

• Hb-15.3
• Wbc - 7,100.
• Neutrophils - 40%
• Lympocytes -50%
• Platelet count- 1 lakhcells/cumm.
• PCV - 44.6

PROVISIONAL DIAGNOSIS:

Viral pyrexia with thrombocytopenia secondary to dengue NS1 POSITIVE with polyserositis 

(Right sided pleural effusion and mild ascites).

TREATMENT:

1. Ivf NS/RL/DNS continuous at 100ml/hr
2. Inj. PAN 40mg IV BD 
3.  inj. ZOFER 4mg IV/SOS
4. Inj. NEOMOL 1gm IV/SOS
5. Tab. PCM 650 mg PO/ SOS
6. Inj. OPTINEURON 1 Ampoule in 100ml NS IV/OD over 30mins.

13/06/2022

1. Oral Fluids
2. Tab.dolo650mg/po/sos.
3. Tab.pan 10mg/po/od.
4. Tab.doxycycline 100mg/po/bd.
5. Tab.zincovit po/od 
6. Vitals monitoring.