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
4 September 2022
A 50 year old female came to the Hospital with the chief complaints of
* Fever since 1 week
* Generalized weakness since 1 week
* Heavy menstrual bleeding 2 days ago
History of present illness :
* Patient was apparently asymptomatic 1 week ago then she developed fever which of low grade, continuous in nature , not associated with chills and relieved on medication, and is associated with generalized weakness.
* She got her menstrual bleed 10 days before and flow was high compared to previous cycles for which she went to hospital and was given medication and one day later , she went to hospital for checkup and was found to be having low platelet count and dengue NS1 reactive and was referred for further management.
* Then she had Nausea since 1 week and it is not associated with vomitings
* She had black coloured stools since yesterday evening.
History of Past Illness :
* No History of Similar Complaints in the Past.
* Not a Known Case of DM, TB , Asthma, Epilepsy, Coronary Artery Disease.
Personal history:
Diet - Mixed
Appetite - Decreased
Sleep - Adequate
Bowel movements - Regular
Bladder Movements - Regular
Addictions - None
Family History :
Not significant
Physical Examination :
A. General Examination
* Patient is conscious, coherent and co-operative and lying on the bed.
* She is well oriented to time, place and person.
* She is mildly nourished.
Pallor - Absent
VITALS AT THE TIME OF ADMISSION:
Temperature - 98.8 F
Pulse Rate - 77 BPM
Blood Pressure - 120/90 mm Hg
Respiratory Rate - 18 CPM
SPO2 - 100% at Room Air
Random Blood Sugar - 95 mg/dl
Systemic Examination :
CARDIOVASCULAR SYSTEM - S1 and S2 present, No murmurs
RESPIRATORY SYSTEM - BAE +, NVBS
PER ABDOMEN - Soft and Non tender, Scaphoid shaped abdomen ,
No free fluid ,
No palpable mass,
No organomegaly .
CENTRAL NERVOUS SYSTEM - E4V5M6, Moving all the four limbs against gravity.
Investigations
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