General Medicine
02,September, 2022.
On 2/9/22
Blood transfusion was done.SDP(280ml)
MEDICATIONS
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 27 year old male came to the OPD with the chief complaints of fever since 3 days and body pains since 3 days.
Swelling of scrotum and right lower limb yesterday night. Admitted in the hospital on 01/09/22.
HISTORY OF PRESENT ILLNESS
Patient was asymptomatic 2 days ago,then developed headache,bilateral frontal area,which is insidious in onset,gradual in progression and relieved on taking medication.
Swelling of scrotum which is sudden in onset,gradually progressive, associated with pain which is continuous and and swelling of right lower limb(pitting type)and present till ankle,for which he was taken to local hospital, and on investigation found the platelets to be low and therefore referred here.
Low grade fever not associated with chills and rigors. Burning micturition -ve,black colored stools-ve,giddiness-ve,red colored urine -ve.
HISTORY OF PAST ILLNESS
Not a known case of Diabetes mellitus and hypertension.
Deafness present since birth.
TREATMENT 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- labourer
Diet-mixed
Appetite -normal
Bowels-regular
Micturition-Normal
Habit/addictions-alcohol occasionally
FAMILY HISTORY
No Diabetes, hypertension, Heart disease, stroke, cancers, tuberculosis,asthma etc.
GENERAL EXAMINATION
No pallor
No icterus
No cyanosis
No clubbing of fingers/toes
No lymphadenopathy
No oedema of feet
No malnutrition
No dehydration
VITAL SIGNS
Temperature-99°F
Pulse rate-82/min
Respiratory rate -16/min
Blood pressure -110/80 mmHg
Spo2-97%at room air
GRBS-107 mg/dL
SYSTEMIC EXAMINATION
CVS
No thrills
S1S2 sounds heard
No cardiac murmurs
RESPIRATORY SYSTEM
Position of trachea-central
Vesicular breath sounds heard
No dyspnea
No wheeze
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
Bowel sounds are heard
CNS
Level of consciousness-conscious/alert
Speech- aphasic
Signs of meningeal irritation
No stiffness of neck
Kerning's sign:negative
Reflexes
Biceps Triceps supinator knee ankle
Right ++ ++ ++ ++ +
Left ++ ++ ++ ++ +
Plantars-flexor
Cerebellar Signs
Finger nose In-coordination:No
Knee heel In-coordination :No
PROVISIONAL DIAGNOSIS
Dengue with thrombocytopenia.
INVESTIGATIONS
On 1/9/22
Ultrasound report
ECG
On 2/9/22
Ultrasound report
RECORDINGS
DIAGNOSIS
Dengue with thrombocytopenia
Right funiculitis with minimal hydrocoele,diffuse scrotum wall edema.
MEDICATIONS
