50 Year Old Male

This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from an available global online community of experts to solve those patients clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcome.

I’ve 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.
Date of Admission 30-10-22

50 Year old male came to Casuality with 
Chief complaints : Fever and Chills Since 1 week
 Associated with Frontal Headache. 
History of Present illness
Patient was Apparently Asymptomatic 1 week Back Then He developed Fever Associated with Chills which was Intermittent in Nature and was Relieved by Medication.It was Also associated with B/l Frontal Headache.No History of Vomiting,Loose Stools or Abdominal Pain.


Past History
Not A K/C/O HTN,Asthma,Epilepsy.
No Allergies 
No Past Surgical History
Personal History 

Diet -Mixed
Appeteite- Decreased 
Bowel And Bladder Movements Regular
Addictions Absent

Family History
No Significant Family History.
Provisional Diagnosis :
Viral Pyrexia

Vitals
Bp 100/60 mmHg
Pulse 75BPM
RR 14cpm
GRBS 437 mg/dl
Pt Is C/C/C well oriented with Time,Place and Person 
Pallor Absent
Icterus Absent
Clubbing Absent
Koilonychia Absent
Lymphadenopathy Absent
Edema Absent

Systemic Examination
CVS
S1 S2 Heard 
RS
BAE Present
P/A
Soft ,Non Tender.
Provisional Diagnosis
Viral Pyrexia 
Investigation
Chest X Ray :


30-10-22
28-10-22

Rapid Dengue - NS1 Positive
30/10/22
 Urine Sugars - Present
Albumin Nil
30-10-22
Platelet Count - 27000


Treatment
Tab PCM 
Inj Neomol 
Inj Zofer  4mg IV SOS
Inj Piptaz 4mg IV BD
Tab Doxy 100mg PO BD

SOAP NOTES DAY 1
Viral Pyrexia  Secondary to Dengue
Thrombocytopenia
Vitals
Bp 120/80
PR 75
GRBS 228mg/dl

Treatment :

Tab PCM 
Inj Neomol 
Inj Zofer 4mg IV SOS
Inj Piptaz 4mg IV BD
Tab Doxy 100mg PO BD

Soap Notes Day 2
Viral Pyrexia Secondary to Dengue
Thrombocytopenia
Bp 110/80
PR 80
GRBS 190 -8Aam

Treatment
Inj Piptaz 4mg IV BD
Tab Doxy 100mg PO BD
Tab PCM 
Inj Neomol 
Inj Zofer 4mg IV SOS
Tab Pan 40mg PO OD



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