General Medicine

A 50 Year old female of Dengue with thrombocytopenia.

01,September, 2022
E LOG 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 years old female came to OPD with the chief complaints of fever(high grade),not associated with chills and rigors since 1 week. 
Admitted in hospital on 01/09/22.

HISTORY OF PRESENT ILLNESS 
She came to hospital with the complaints of fever, not associated with chills and rigors. 
Vomitings since yesterday,5-6 episodes.food particles as content.
Loose stools,3-4 episodes per day since 3 days.Dark colored stools are seen.no hematuria. 

HISTORY OF PAST ILLNESS 
Known case of hypertension since 1 year.

TREATMENT HISTORY 
Hypertension-on medication
No Diabetes,CAD, Asthma,Tuberculosis,hormones , chemo/Radiation ,transfusion , surgeries etc.

PERSONAL HISTORY 
Married 
Occupation-Housewife
Appetite-normal 
Diet-mixed
Bowels-regular 
Micturition-normal 
No allergies 
No addictions 

FAMILY HISTORY 
No Diabetes , Hypertension , Heart disease , stroke,cancers,TB, Asthma etc.

GENERAL EXAMINATION 
No pallor 
No icterus 
No cyanosis
No clubbing of fingers /toes
No malnutrition 
No dehydration 

VITALS 
Temperature-99°F
Pulse rate-88/min 
Respiratory rate-14/min
Blood pressure-(left arm)-130/80mmHg
SpO2 at room air-98%
GRBS-112mg/dL

Reflexes 
            Biceps  Triceps  supinator  knee ankle 
Right    ++             ++         ++            ++        +
Left        ++          ++           ++            ++       +
     Plantars-flexor 

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

PROVISIONAL DIAGNOSIS 
Viral pyrexia 

INVESTIGATIONS 


               ECG
                  Ultrasound report 
RECORDINGS 
MEDICATIONS 

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