This is an a online e log book to discuss our patient 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 problem with collective current best evident based input.
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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.This is an a online e log book to discuss our patient 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 problem with collective current best evident based input.
Manogna P
Roll no. 120
A 60 year old male farmer by occupation came to OPD with chief complaints of:
Fever since 15days
Hematuria since 5days
Shortness of breath since 5days
HOPI:
Patient was apparently asymptomatic 15days then he developed fever which is intermittent associated with chills and rigors, for which he was taken to a local hospital where he tested positive for dengue(NS1) for which he was treated.
2 Single donor platelets tranfusion(SDP) were done.
During the hospital stay he had blood in the urine and Shortness of breath(Grade 2)
Then he was discharged.
After the discharge he again developed fever which is intermittent, associated with chills and rigors, heamturia, and Shortness of breath which progressed to Grade 3.
For which he was brought to our Hospital
Pleural effusion-pleural tap was done.
H/o Asthma since 3years for which he used inhalers
Not a known case of diabetes,HTN,epilepsy,CAD
Personal History:
Diet: Mixed
Appetite: decreased
Sleep: disturbed
Bowl habits: regular
Bladder habits: Hematuria since 5days
Addictions: Alochol- 1 or 2 times a week(90ml)
H/o- Smoking Chutta since 25years
Family History:
No significant Family history
GENERAL EXAMINATION
Patient is conscious, coherent, and
co-operative and well oriented to time and place.
He is mildly malnourished.
No Pallor, Icterus, Clubbing, Cyanosis, Lymphadenopathy, edema
Vitals :
Temp - 101 degree f
Pr -88 bpm
RR -34 cpm
Bp -120/70 mmHg
Spo2 - 96 % at RA
GRBS -110 mg/dl
Systemic Examination:
CVS - S1, S2 heard
Rs - dyspnea
Position of trachea -central
Percussion : dull note over right infra-scapular ,infra axillary region
Auscultation : decreased breath sounds on right infra mammary , infra axillary and infra scapular areas
Per abdomen : soft ,non tender , no organomegaly , bowel sounds heard
CNS - no focal neural deficits.
Investigations:
Provisional Diagnosis:
Fever under evaluation
Hematuria under evaluation
Pleural effusion(Right side)
Treatment:
Therapeutic pleural tap Of 400ml was done.
1. Head end elevation
2.o2 inhalation to maintain spo2 >=96%
3.inj tranexa 500 mg IV/stat
4.inj pantop 40 mg IV/stat
5.inj Zofer 4mg iv/sos
6.neb with budecort iv/stat
7.inj Neomol 100 ml iv/tid
8.tab pcm 650 mg po/sos
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