Hello all this is G Shreyaa eighth semester student.This E Log depicts the patient centered approach to learning
Fever charting on 25 and 26 -10-23
Systemic examination
Provisional diagnosis :-
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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 -10-23Systemic 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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