A 60 Year Old Female With Fever and Backache and Generalised Weakness.
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
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.
Ankur Kumar
Roll no 14
A 60 Year Old Female With Fever and Backache and Generalised Weakness Since 5 Days
CHIEF COMPLAINTS
Fever Since 5 Days
Backache since 5 Days
Generalised Weakness Since 5 Days
HOPI
Patient was Apparently asymptomatic 5 days back and then developed sudden onset of high grade fever which is Continuous and with no diurnal variation and Not associated with Chills and Rigors.
She complained of Backache since 5 days which is insidious in onset ,gradually progressive, and is persistent.
She also Complained about Generalised Weakness Since 5 days.
She went to a Government Hospital with complaints of Fever and Generalised Weakness 4 Days ago Where She was Diagnosed With Hypotension and Low Platelet Count.
She was Put on Medication But as her Symptoms Were not relieving, She came to this Hospital for treatment.
PAST HISTORY
No history of Hypertension, Diabetes, Asthma, Epilepsy,TB
No history of prolonged hospital stay
No history of previous surgeries
PERSONAL HISTORY
DIET - Mixed
Appetite - Decreased
Sleep - Inadequate
Bowel and Bladder - Regular
Addictions - Tobacco Smoking 2-3 times a Day since 40 years
DAILY ROUTINE
She wakes up at 5am and does her Morning chores.
Drinks Tea at 7am and eats her Breakfast - Rice and Vegetable curry at 9am
And then goes for work.
She works as labourer in the farm fields.
She eats her lunch by 1pm - Rice and vegetable curry
She comes home by 5:30 pm and completes her daily chores and eat dinner by 8:30 pm - Rice and Vegetable curry and goes to sleep by 9 pm.
TREATMENT HISTORY - Unknown
FAMILY HISTORY - Not Relevant
GENERAL EXAMINATION
Patient was Conscious, Coherent and Cooperative
Moderately build and Moderately Nourished
Well oriented to Time ,Place and Person.
Pallor : No Pallor
Icterus: absent
Clubbing: absent
Cyanosis: absent
Lymphadenopathy: absent
Edema : absent
VITALS:
Temp: Afebrile
BP: 80/60 mmHg in Supine position
PR- 90 bpm
RR- 30 CPM
SYSTEM EXAMINATION:-
Abdominal Examination-
INSPECTION :-
On Inspection Abdomen is Slightly Distended,
Umbilicus is central and Slit Like ,
No scars and Sinuses
No Engorged Veins
PALPATION
All inspectory findings are Confirmed
Tenderness Present in the Right Hypochondrium Region
No Flank Fullness
Percussion
- No Significant Findings
Auscultation
- Bowel Sounds Heard
RESPIRATORY EXAMINATION
Trachea central,
Bilateral Air Entry Present
Normal vesicular breath sounds.
CARDIOVASCULAR SYSTEM
S1 ,S2 heard ,
No murmurs
CNS EXAMINATION
No Focal Neurological Deficits
INVESTIGATIONS
FEVER CHART
PROVISIONAL DIAGNOSIS
Dengue Fever, With Thrombocytopenia
Comments
Post a Comment