E-LOG MEDICINE

GENERAL MEDICINE


                                                         -108 Koushik



This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

 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, come up with a diagnosis and treatment plan.


Chief complaints:

A 30 yr old male came to OPD with chief complaints of fever,swelling in the hands,swelling in the legs and slight body pains.

History of presenting illness:

Patient was apparantly asymptomatic 4 days back then he developed itching and fever which was intermittent , associated with chills and relieved on medication and has slight body pains.


History of past illness:

N/k/c/o of Diabetes,HTN,TB, epilepsy,asthma.


Daily routine:

He wakes up at 6 am 

She does his breakfast by 8:00 AM mostly rice

He goes to work in the farms

He has lunch at 1:00 pm 

He then leaves for work.

He takes his dinner around 8 pm(rice)

He sleeps  at 9 - 10 pm.

On the day of occurence of fever he went for construction work(laying tiles) and had hotel food, after sometime around 3-4 pm he developed itching and fever and went to local RMP for which he gave some injection.


Family history:

No significant family history.


Personal history:

Appetite normal.

Mixed diet.

Regular bladder and bowel movements.

Addictions:

Alcohol taken daily since 15 yrs.

Sleep is normal.


General examination:

Patient is c/c/c well oriented to time and place .

BP:110/80mm hg.

PR:78bpm

RR:16cpm

No pallor/icterus /cyanosis/clubbing/lymphadenopathy/









Systemic examination:

Cvs:

S1,S2heard.
No thrills and cardiac murmurs

Respiratory system:

Dyspnea:absent
No wheezing
Position of trachea central
Breath sounds vescicular
BAE +ve

Per abdomen :

Soft ,non tender,palpable mass present
Liver,spleen not palpable.

CNS :
 nad

Investigations:


Provisional diagnosis: Viral pyrexia with dengue


Treatment:

I.V.Fluids NSRL 75ml/hour
Inj NEOMOL 1gm/iv
Inj.PAN 40mg/iv
Tab.DOLO 650 mg
Tab.MVT
Monitor vitals



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