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.


38yrs old male pt came to casualty complaining of fever since 15days, on and off, associated with chills which subsided on taking medication

No h/o cough, cold, nausea, vomiting 
h/o burning micturition sonce 10days 
No h/o hematuria or frothy urine
h/o pedal esema, b/l pitting type

Not a K/c/o DM, HTN, bronchial asthma , TB, epilepsy
tested positive for dengue IgM on 2/10
 personal history- appetite- lost 
vegetarian
bowel and bladder- regular 
alcohol consumption- regularly since 20yrs whiskey 90ml
smoked a pack daily for 20yrs
ON EXAMINATION
PT is C/c/c
Icterus present
No pallor, cyanosis, lymphadenopathy  and no pedal edema 
Temp- 98.6 
PR- 72/MIN
RR-18 cpm
BP- 110/70 mm Hg

CVS- S1 S2 +
RS- Position of trachea central, vesiclular breath sounds +
L ISA Inspiratory wheeze +
L inspiratory crepitations ISA, IAA
per abdomen- scaphoid, no tenderness,
CNS- HMF INTACT

Provisional diagnosis- viral pyrexia ? hepatitis secondary to alcohol
Hemogram on 8/10/21:



Soap notes day 2
Ward case
S- 1 fever spike (101°f)

O- 
Icterus present
Bp- 100/60mm hg
Pr- 84/min
Cvs-s1,S2 +
Rs- bae+
Left infraclavicular expiratory wheeze+
B/l inspiratory crepts+,ISA,IAA (L)
P/A- soft, nontender
Bs+
Cns- hmf intact

A- viral pyrexia with thrombocytopenia with indirect hyperbilirubinemia

P- 
1.IVF 1 unit of NS with optineuron 1Amp IV @50ml/ hr
2.inj. thiamine 1Amp in 100ml NS
3. Inj. Methyl cobalamine 1000 micro gram IM OD
4. Inj. Pan 40mg IV OD BBF
5.Tab. udiliv 300mg PO BD
6. Bp/pr/temp charting 8th hrly
7.inform SOS
8.GRBS charting 8th hrly
 
Reports on 9/10/21
Hemogram

LFT
Soap notes day 3
Ward case
S- no fresh complaints

O- 
Bp- 110/60mm hg
Pr- 72/min
Cvs-s1,S2 +
Rs- bae+ , NVBS , clear
P/A- soft, nontender
Bs+
Cns- hmf intact

A- viral pyrexia with thrombocytopenia with indirect hyperbilirubinemia

P- 
1.IVF 1 unit of NS with optineuron 1Amp IV @50ml/ hr
2.inj. thiamine 1Amp in 100ml NS
3. Inj. Methyl cobalamine 1000 micro gram IM OD
4. Inj. Pan 40mg IV OD BBF
5.Tab azithral 500mg /PO/BD
6.Tab. udiliv 300mg PO BD
7. Bp/pr/temp charting 8th hrly
8.inform SOS
9.GRBS charting 8th hrly

Soap notes day 4
Ward case
S- no fresh complaints

O- 
Bp- 110/70mm hg
Pr- 74/min
Cvs-s1,S2 +
Rs- bae+ , NVBS , clear
P/A- soft, nontender
Bs+
Cns- hmf intact

A- viral pyrexia with thrombocytopenia with indirect hyperbilirubinemia

P- 
1.IVF 1 unit of NS with optineuron 1Amp IV @50ml/ hr
2.inj. thiamine 1Amp in 100ml NS
3. Inj. Methyl cobalamine 1000 micro gram IM OD
4. Inj. Pan 40mg IV OD BBF
5.Tab azithral 500mg /PO/BD
6.Tab. udiliv 300mg PO BD
7. Bp/pr/temp charting 8th hrly
8.inform SOS
9.GRBS charting 8th hrly
Soap notes day 5
Ward case
S- no fresh complaints

O- 
Bp- 110/80mm hg
Pr- 74/min
Cvs-S1,S2 +
Rs- bae+ , NVBS , clear
P/A- soft, nontender
Bs+
Cns- hmf intact

A- viral pyrexia with thrombocytopenia with indirect hyperbilirubinemia

P- 
1.IVF 1 unit of NS with optineuron 1Amp  IV @50ml/ hr
2.inj. thiamine 1Amp in 100ml NS
3.Tab Pan 40mg IV OD BBF
Tab. Glimi M1 / PO/ OD
4. Bp/pr/temp charting 8th hrly
5.inform SOS
6.GRBS charting 8th hrly 

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