55 year old female suffering from VIRAL PYREXIA with THROMBOCYTOPENIA
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 55 year old female who is home maker came to OPD with complaints of fever associated with chills and rigor , vomitings, burning micturition , burning sensation of both feet , backpain .
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1 year ago.
Then she started having fever which is recurrent in nature which subsided on medication.
They then visited a diagnostic centre for CBP where they were said to have low platelets.(31 ,000)
She came to our OPD with complaints of
* Black stools since 7 days .
* Fever associated with chills and rigors ( on and off) , vomitings ( more than 3 episodes per day ), burning micturition since 3 days .
* C/o burning sensation of both feet , backpain not radiating to legs since 3 days .
PAST HISTORY:
K/c/o Diabetes mellitus on medication.
Not a k/c/o hypertension.
Surgical history:appendectomy, hysterectomy.
PERSONAL HISTORY
Diet:Mixed
Appetite:Normal
Sleep: Adequate
Bowel and Bladder movements:Black colored stools at the time of presentation ,normal micturition.
No addictions .
No allergies.
FAMILY HISTORY
Not relevant
TREATMENT HISTORY
On medication for Diabetis mellitus (Oral hypoglycemic agents) since 1 year
GENERAL EXAMINATION
Patient is coherent,conscious and cooperative .
Patient is well nourished.
No pallor, icterus, clubbing, cyanosis,lymphadenopathy,edema.
Vitals
Temperature :99°F
Blood pressure : 150/90 mm Hg
Pulse rate:87
Respiratory Rate:
Spo2 :97 percent
SYSTEMIC EXAMINATION:
Cardiovascular System: S1 and S2 heard.
No murmurs heard.
Respiratory system: vesicular breath sounds heard.
Position of Trachea: Central
Per abdomen:
Shape of abdomen: obese
No tenderness
No organomegaly.
Bowel sounds heard
Central nervous system:
Conscious
Normal speech.
PROVISIONAL DIAGNOSIS:
Viral PYREXIA with thrombocytopenia.
INVESTIGATION:
Comments
Post a Comment