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 26 year old male patient who is farmer by occupation came to the OPD with chief complaints of fever and swelling of legs since 7 days and loss of appetite since 5 days.
HOPI:Patient was apparently asymptomatic 1 week back ,then he had one episode of low grade fever,relieved with medication,associated with generalised body pains ,not associated with cough, burning micturition.
Then developed pedal edema ,intially till ankle , gradually progressive ,pitting type.
Loss of appetite since 4-5 days associated with nausea .
One episode of vomiting 4 days back which is non bilious ,non projectile,food particles as content.
Past History:
Rat bite present 4 - 5 months back
Know case of edema.
Personal History:
Diet:mixed
Sleep: disturbed due to pain
Appetite:normal
Bowel bladder movements: regular
Addictions: alcohol consumption since 15 years and chewing of tobacco.
Family History:
No significant
General Examination:
Patient is conscious,coherent and cooperative well oriented to time,place,person
Pallor + (unhealthy)
Icterus + (sings of jaundice)
No cyanosis/ clubbing/ lymphadenopathy
Vitals:
Temp:98.6 F
Pr:72bpm
Bp:130/80
Spo2:96%
RS : BAE +
P/A : soft non tender
Provisional Diagnosis :
Sepsis MODS secondary to ? Leptospirosis
Severe thrombocytopinea
c/o no fever spikes appetite improved
conjuctival suffusions decreased.
Investigation :
LFT. 8-04-22
TB: 4.64 -4.43
BB: 3.69-2.10
SGOT : 57-47
SGPT : 46-29
ALP : 320-285
TP : 5.6-5.1
ALB : 3.47-2.92
ALG : 1.63-1.34
Serum amylase : 154
Serum lipase : 62
Serum creatinine : 4.9-4.2
RBS : 92 mg/dl
Blood urea : 129 mg/dl - 134 mg/dl
Sodium - 136-139
K - 3.5-3.7
Chlorine - 104-103
Calcium - 9.6
CBP : Hb - 20.4 gm/dl
TC - 17,700
PLT - 60,000
N/L/E/M - 75/18/0/7
APTT-36 sec
BT - 2min 00 sec
CT- 5 min 00 sec
PT - 18 sec
INR - 1.3
Diagnosis:
Pedal edema , jaundice
Severe thrombocytopinea.
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