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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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.
A 40 year old patent
Presented with fever since 3 days and headache since 2 days.
HOPI -
Patient was apparently asympatic 5 days backwhich was sudden and proggressive ,continuos and associated with chills and rigors, and there was no diurnal variationfor which he reached to hospital took medication and fever subsided and went back home later the fever spiked in the night of same day next day morning 1/3/22 (which was treated with medications).
Past history- not significant
Not a /k/ case of d.m,htn,asthma,tb
Personal history:-
Nrmal sleep,mixed diet,regular appetite ,normal bowel movement,no burning micturition ,no addictions,no k own allergies
Family history:- not relevant
General examination:-
Patient was well built and well nourished
PICKLE- NEgative
Vitals at admission-
Bp-110/70 ;pr-84bpm; rr-16cpm ;
grbs-134mg/dl ; spo2-98% at RA
Systemic examination:-
CVS: S1S2 heard, no murmurs
RS: BAE+ NVBS+
P/A: Soft, Non-tender
CNS: NAD
INVESTIGATIONS:-
NS 1 antigen positive
Platelets count ; 55000
PROVISIONAL DIAGNOSIS:-viral pyrexia with throbocytopenia (?) With ns1 positive
Treatment
1)inj optineurin in 100ml NS over 30 min
2)paracetmol 650mg tid
3) IVF at 150 ml/ hr
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