General medicine case 1

This is an online e logbook to discuss our patients deidentified health data shared after taking her/guardian's signed informed consent

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs

A 33yr old male resident of kattamgur, watchman by occupation came to our hospital with complaints of fever since 5 days, headache since 5 days, left sided chest pain since 3 days and cough since 1 day 


He was apparently asymptomatic 5 days back then developed low grade continuous fever which was not associated with chills and rigors, no diurnal variations and relieved on taking medication. 
Fever was followed by headache which is diffuse in nature and not associated with nausea or vomiting 
He had c/o dry cough not associated with shortness of breath, orthopnea and paroxysymal nocturnal dysnpea and C/o left sided chest pain since 3days which was pricking type and non radiating. Patient had no h/o palpitation, syncopal attacks and burning micturition 
There was no any h/o trauma 
He is a k/c/o alcoholic and drinks 90ml occasionally and not a smoker 
He has no h/o DM, HTN, TB, epilepsy.
There were no similar complaints in the past

On examination patient was conscious, coherent, cooperative and has no Pallor, icterus, cyanosis, clubbing, lymphadenopathy and Edema. 
He had no signs of dehydration 
He was afebrile with bp of 110/80mmhg, Pulse was 98bpm, Respiratory rate was 22 cpm and his spo2 was 99% on room air and his grbs was 115mg/dl 

His systemic examination findings were 
CVS - S1, S2 heard and no murmurs 
RS - Bilateral air entry present with normal vesicular breath sounds but breath sounds were deceased on auscultating RIA and IAA regions 
His abdomin was scapoid in shape with no tenderness, papalable masses, bruits and organomegalies 
His CNS examination was normal 

Fever charting 



Investigations 
Hemogram 

CUE 
  
RFT
    Sr. urea - 51 (increased)
    Sr. Creatinine - 1.1 (N)
    Sr. Na - 131 (decreased)
    Sr. K - 3.9 (N)
    Sr. Cl - 97 (slight decrease)
LFT

APTT - 32 sec
BT - 2mins 
CT - 4 min 30 sec
SARS COVID 19 - negative

Chest X ray 


Serology - negative 
Blood grouping and typing - B positive 
Patient was positive for ns1 antigen testing

PROVISIONAL DIAGNOSIS  - Dengue fever with platelet count of 50000 cells/cumm

TREATMENT 
 
DAY 0
His vitals were 
Temperature- 98.6F
BP- 110/70 mmhg
Pulse rate - 80 bpm
Respiratory rate- 16 cpm
GRBS 102mg/dl
Systemic examination was normal 
Hb- 17.5
TLC - 5000
Platelet count is 8000

IV Fluids 3NS and 1RL at 100ml/hr with 1 Amp optineurin
 - Adviced to take plenty of oral fluids 
 - TAB. DOLO 650mg/ PO/ SOS
 - TAB. DOXCYCILIN 100mg PO/OD
 - TAB. PAN 40mg PO/BBF
 - Syrup AMBEONLY PO TID 5ml

Day 1
patient had no new complaints 
His vitals were 
Temperature- 99 F
BP- 110/80 mmhg
Pulse rate - 85 bpm
Respiratory rate- 17 cpm
GRBS 110 mg/dl
Systemic examination was normal 
Hb - 17.5
TLC - 5.0
Platelet count is 8000
So patient underwent SGPT after which his platelet counts were 33000
Patient was put on 
 - IV Fluids 3NS and 1RL at 100ml/hr with 1 Amp optineurin
 - Adviced to take plenty of oral fluids 
 - TAB. DOLO 650mg/ PO/ SOS
 - TAB. DOXCYCILIN 100mg PO/OD
 - TAB. PAN 40mg PO/BBF
 - Syrup AMBEONLY PO TID 5ml

Day 2
patient had no new complaints 
His vitals were 
Temperature- 98.4F
BP- 110/70 mmhg
Pulse rate - 74 bpm
Respiratory rate- 16 cpm
GRBS 127mg/dl
Systemic examination was normal 
Hb - 14 g/dl
TLC - 3.15
PCV - 32.2
Platelet count is 44000
IV Fluids 3NS and 1RL at 100ml/hr with 1 Amp optineurin
 - Adviced to take plenty of oral fluids 
 - TAB. DOLO 650mg/ PO/ SOS
 - TAB. DOXCYCILIN 100mg PO/OD
 - TAB. PAN 40mg PO/BBF
 - Syrup AMBEONLY PO TID 5ml


Day 3
patient had no new complaints 
His vitals were 
Temperature- 98 F
BP- 110/80 mmhg
Pulse rate - 79 bpm
Respiratory rate- 16 cpm
GRBS 107mg/dl
Systemic examination was normal 
Hb - 11.5 g/dl
TLC - 3.37
PCV - 32.2
Platelet count is 75000
IV Fluids 3NS and 1RL at 100ml/hr with 1 Amp optineurin
 - Adviced to take plenty of oral fluids 
 - TAB. DOLO 650mg/ PO/ SOS
 - TAB. DOXCYCILIN 100mg PO/OD
 - TAB. PAN 40mg PO/BBF
 - Syrup AMBEONLY PO TID 5ml


Day 4
patient had no new complaints 
His vitals were 
Temperature- 98 F
BP- 110/80 mmhg
Pulse rate - 79 bpm
Respiratory rate- 16 cpm
GRBS 107mg/dl
Systemic examination was normal 
Hb - 13.7 g/dl
TLC - 4800
PCV - 32.2
Platelet count is 1.5 lakh 
IV Fluids 3NS and 1RL at 100ml/hr with 1 Amp optineurin
 - Adviced to take plenty of oral fluids 
 - TAB. DOLO 650mg/ PO/ SOS
 - TAB. DOXCYCILIN 100mg PO/OD
 - TAB. PAN 40mg PO/BBF
 - Syrup AMBEONLY PO TID 5ml

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