General Medicine

24,August, 2022
A 50 year old women with viral pyrexia associated with thrombocytopenia 

ELOG GENERAL MEDICINE 

Hi, I am Pindi Gayatri , 3rd Sem Medical Student.This is an 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 patient's 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 the 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 a diagnosis and treatment plan.

CHIEF COMPLAINTS 
A 50 year old female came to the casuality with the complaints of fever and swelling of both the legs since 3 days.

HISTORY OF PRESENT ILLNESS 
She came to the casuality with the history of fever since 4 days ,diurnal variation, increased temperature at night. 
     Constipation since 2 years.Passes stools once every 3 days.
     Loose stools 4 days back,(6 episodes),mucous with no Blood. 
      Generalized Weakness is felt.
    Bilateral pedal edema since 3 days.she was not able to stand and walk. Vomitings-daily 2-3 times,Burning micturition.No SOB.

She visited the nearby hospital before-3 days for the same reason of fever and swelling of the legs.

HISTORY OF PAST ILLNESS 
Not a known case of hypertension, Diabetes, epilepsy, CAD,Asthma, Thyroid, etc.

TREATMENT/DRUG HISTORY 
No Diabetes 
No hypertension 
No CAD
No Asthma 
No Tuberculosis 
No Antibiotics 
No Hormones 
No Chemo/Radiation 
No Blood transfusion 
No surgeries 

PERSONAL HISTORY 
Married 
Occupation-work in fields 
Diet-mixed
Appetite-normal
Bowels-regular
Micturition-normal 
No known Allergies 
Habits/addictions -no drug use,betel leaf and betel nut.

FAMILY HISTORY 
Not significant 

GENERAL EXAMINATION 
No pallor 
No icterus
No cyanosis 
No clubbing of fingers 
No lymphadenopathy 
oedema of feet -present
No malnutrition 
No dehydration 

VITALS
Temperature-Afebrile 
Pulse rate-96 bpm
Respiratory rate-16cpm
Blood pressure-120/70 mmHg(left arm)
SpO2 at room air-98%/at RA litres of 02
GRBS-101 mg/dL

SYSTEMIC EXAMINATION 
CVS
No thrills
S1S2 sounds heard 
No cardiac murmurs 
RESPIRATORY SYSTEM 
Position of trachea-central 
Vesicular breath sounds heard 
Adventitous sounds -Rhonchi
No dyspnea 
No wheezing 
ABDOMEN
Shape of the abdomen-scaphoid 
No tenderness 
No palpable masses
Normal hernial orifices 
No free fluid 
No bruits
Non palpable liver
 Non Palpable spleen
 No Bowel sounds 
CNS
Level of consciousness-conscious/alert 
Speech-normal 
Signs of meningeal irritation 
         No stiffness of neck 
          Kerning's sign:negative 

Reflexes
       Plantars-flexor 

Cerebral Signs
Finger nose In-coordination:No 
Knee heel In-coordination :No

PROVISIONAL DIAGNOSIS 
Viral pyrexia associated with thrombocytopenia 

INVESTIGATIONS 
On 20th of August 
On 21st of August 
           ECG

Doppler-2D Echo
        Ultrasound report 


On 23rd of August 
RECORDINGS
DIAGNOSIS 
      Viral pyrexia associated with thrombocytopenia     ?LEPTOSPIRA
      Acute GE               
      AKI
    ?  Right Heart failure 
 ?LEPTOSPIROSIS
      AKI 2°to ?leptospira
Dengue Ns1Ag test:Negative 

TREATMENT 


     

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