A 20 YEAR OLD MALE
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This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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.
A 20yr old male presented to the casualty at 4pm with complaints of
Fever since 4days and
Reddish dots over the back and both lowerlimbs since 1day
HOPI:
Pt was apparently asymptomatic 4days back, then developed fever which is low grade, intermittent, not associated with chills and rigors, relieved on taking medication
Next day the patient had one episode of black colored loose stools
Since 2days patient had 5 episodes of vomitings which are non bilious and non projectile, non foul smelling with food as content
Since 1day patient had reddish dots over and both lower limbs so he visited nalgonda hospital where he told to have low platelet count(23,000) and was reffered to kims narketpally
Past history :
No similar complaints in the past
Not ak/c/o HTN, DM, EPILEPSY, TB, ASTHMA
Personal history :
Diet: vegeterian
Appetite : decreased
Bowel and bladder movements : regular and normal
No addictions.
On examination
Pt is c/c/c
Moderately built and moderately nourished
No signs of pallor, icterus, cyanosis, clubbing, pedal edema, generalised lymphadenopathy
Vitals on admission :
Bp:110/70mmHg
SpO2 : 93%on RA.
PR : 63bpm
Grbs: 97mg/dl
Systemic examination :
Cvs: s1 s2 heard
Rs: bae+,nvbs heard
Cns:nad
Per abdomen:soft and non tender
Provisional diagnosis :
?Viral pyrexia with thrombocytopenia
Investigations
On 28/8/21
On 30/8/21
Treatment
On 28/8/21
1.plenty of oral fluids
2.IVF RL,NS @150ML/HR
3.INJ.pan 40 MG/iv/od
4. INJ.ZOFER 4 MG /IV /SOS
5. Tab.pcm 650 mg /po/sos
6. Temp Charting 4 th HRLY
7. W/f bleeding manifestations, postural hypotension
On 29/8/21
1.plenty of oral fluids
2.IVF RL,NS @150ML/HR
3.INJ.pan 40 MG/iv/od
4. INJ.ZOFER 4 MG /IV /SOS
5. Tab.pcm 650 mg /po/sos
6. Temp Charting 4 th HRLY
7. W/f bleeding manifestations, postural hypotension
8. Syp.muciane gel 5ml/po/tid
On 30/8/21
SOAP NOTES
Day 3
SUBJECTIVE
No fever spikes
Petechiae present
OBJECTIVE
Bp -90/70 mmHg(supine)
90/70 mmHg (standing 1min)
Pr - 80 bpm
ASSESSMENT
VIRAL PYREXIA WITH THROMBOCYTOPENIA with platelet count-40,000 today
PLAN OF TREATMENT
1.plenty of oral fluids
2.IVF RL,NS @150ML/HR
3.INJ.pan 40 MG/iv/od
4. INJ.ZOFER 4 MG /IV /SOS
5. Tab.pcm 650 mg /po/sos
6. Temp Charting 4 th HRLY
7. W/f bleeding manifestations, postural hypotension
8. Syp.muciane gel 5ml/po/tid
