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 45 year old man , farmer by occupation came to causality with CHIEF COMPLAINT OF:
Body pains since 4 days
Reduced urine output since 3 days
Vomiting yesterday
Hematuria since morning
Black tarry stools since morning
Sob since morning
HISTORY OF PRESENTING ILLNESS:
He had muscle pain which is pinching type which get relived on medication.
High grade fever, intermittent,not associated with chills and rigors .
2 episodes of non projectile, non bilious, blood tinged vomiting yesterday .
He had shortness of breath of grade -4 .and low bp
He was taken to an outside hospital where in he received fluids and later the attenders decided to pay a visit to our hospital.
Hematuria since morning
1 episode of black tarry stool in the morning
PAST HISTORY : NO h/o Diabetes, hypertension,asthma , tuberculosis,epilepsy
He had surgery in abdomen due to presence of perforation on hepatic artery
PERSONAL HISTORY:
DIET:mixed
Appetite:normal
Bowel and bladder: decrease frequecy
Addiction: consume alchol daily (90-180ml/day).smoke (30 cigarettee/day)
GENERAL EXAMINATION
patient was coherent cooperative counsious
Subconjunctival haemorrhage+
Patient was present with subconjunctival haemorrhage
Patient icterus+ and pallor+
Yellow discoloration in nails
Bp was 60mmhg on palpation
PR - 115bpm
RR - 25 cpm
Spo2 - 92% on Room air
Afebrile
Lungs -
Inspiratory crepitations in Bilteral IAA,ISA
Cvs-s1,s2+
Per abdomen-soft non tender
HB - 8 ( outside 2 days back 11g/dl)
TLC - 8400
Plt - 15,000
Total Bilirubin - 11
Direct Bil - 7.05
Ast - 327
Alt - 187
Alp - 303
Albumin - 2.4
Serum creatinine - 2.5
Blood urea - 82
Dengue negative
Abg showing metabolic acidosis with PH 7.32
Hco3 - 9
Pco2 - 19
Po2 - 101 with oxygen on 6L of O2
Diagnosis -
Septic Shock secondary to ? Leptospirosis
Pyrexia with bicytopenia
Direct hyperbilirubinemia and prerenal AKI
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