45 year female with thrombocytopenia
August 22, 2022
This is online E-blog, to discuss our patient de-identified 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 the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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 a diagnosis and treatment plan.
Our 45 yr old female patient came to the opd with chief complaints of
- fever since 10 days .
- Generalised body pains and weakness since 10days
- Shortness of breath since 5 days,
HOPI:-
Patient was Apparently asymptomatic 10 days back then she developed fever Associated with chills which was intermittent in nature relieved by medication a/w generalised body pains and weakness.
Patient developed sob on exertion 5days ago which was gradually progressed to grade II
- No h/o chest pain, palpitations, syncopal attacks.
- No h/o cough,cold
- No h/o abdominal pain,vomitings,burning micturition
Past history:
No similar complaints in the past
Not a k/c/o DM,HTN,TB, ASTHMA, EPILEPSY,CAD
Personal history:
Diet: mixed
Appetite:normal
Sleep: Adequate
Bowels: Regular
Micturition:Normal
No addictions
Family history:
Not significant
General examination:
Patient is c/c/c
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No edema
Vitals:
Temp:99.8F
Bp:100/70mmhg
PR:96bpm
RR:18cpm
Systemic examination:
CVS:S1, S2 sounds heard
RESP:BAE+,clear
P/A:Soft and non tender
CNS:NAD
21/08/2022
22/08/2022
Treatment:
IV fluids 2NS 2RL at 30ml/ hr
Neomol 1gm IV SOS
Tab dolo 650mg po SOS
BP, temp charting 6th hourly
Tab doxy 100;mg po/bd
Tab. Falcigo 120 mg
