Hello all this is G Shreyaa eighth semester student.This E Log depicts the patient centered approach to learning

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.

A 24yr old female patient came to the OPD with chief complaints of fever since 10 days and cough since two days 

HOPI

Patient was apparently asymptomatic 10 days ago then developed high grade fever with chills and rigors which was continuous type and relieved. Temporarily on IV medication. Fever is mainly during the night time. It is associated with headache, generalised weakness and abdominal pain after having food.

Then developed dry cough since two days occasionally which resolves spontaneously 

No c/o Rash retro orbital pain, cold vomiting, loose stools burning micturation, 

no bleeding manifestations 

No c/o chest pain, SOB ,Palpitations decreased urine output orthopnea ,PND 

Past History 

H/o appendicectomy

N/K/C/O HTN, DM ,CAD, seizures TB,seizures, asthma 

Personal history

Mixed diet 

appetite-normal 

Bowel and bladder- regular 

General examination 

Patient was conscious coherent, cooperative

Not adequately built and nourished

Sign of Pallor present. No signs of cyanosis clubbing lymphadenopathy , edema 

Fever charting on 25 and 26 -10-23
Systemic examination 

C V S-S1 and S2 heard no murmurs. RS- NVBS heard trachea is central 

Abdomen- No tenderness, No bruit heard 

INVESTIGATIONS
Provisional diagnosis :-
 Viral Pyrexia with thrombocytopenia 

Treatment

25/10/23

IV fluids -NS -@100ml/hr

   Inj.Neomol 1gm IV/SOS 

Tab.PCM 650mg PO QID

Monitor vitals every 4th hrly

26/10/23

IV fluids -NS -@100ml/hr
   Inj.Neomol 1gm IV/SOS 

Tab.PCM 650mg PO QID

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