This is an online E log book 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 available global online community of experts with an aim to solve those patient's 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 is welcome.

Here is a case i have seen:

CASE DISCUSSION

63 year old female came with complaints of fever since 5 days and headache since 5 days 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 5 days back when she developed fever with headache , fever was low grade , intermittent in nature and increased at night 

Headache was continuous in parietal region non radiating, without any aggrevating , relieving factors ( no medication ) 

No h/o vomitings, loose stools,blood in stools, rash, sore throat, cough, 

Past History

4 months ago patient complained of fever , taken to nalgonda government hospital where she was diagnosed with anemia and thrombocytopenia. Similar history 2 months back when fever subsided on taking medication 











Not a k /c/o DM , HTN, TB , epilepsy , asthma

H/o abdominal surgery 25 years back 

PERSONAL HISTORY

Patient is a vegetarian with decreased appetite having adequate sleep and normal bowel and bladder habits and no addictions

ON EXAMINATION 

PT is conscious, coherent, cooperative

Pallor - present , lymphadenopathy - absent , icterus - absent , clubbing - absent , cyanosis - absent 

VITALS:

Pr - 86bpm 

RR - 20CPM

BP - 110/60mmhg 

 temp - 100F 


SYSTEMIC EXAMINATION :

CVS - S1 S2 + , no murmurs

RS - BAE+ ,NVBS 

P/A - soft , non tender

CNS - no abnormality detected



















Serum iron- 83

STOOL FOR OCCULT BLOOD +

PROVISIONAL DIAGNOSIS-  PANCYTOPENIA UNDER EVALUATION

TREATMENT GIVEN:1

1. Inj. Optineuron 1 ampoule in 100ml       NS/IV/OD  

2. Tab. PCM 650 mg/SOS 

3. Tab. MVT OD/PO 

4. Tab. Pan 40mg OD/PO 

5. Tab. Folate 5mg/OD 

6. Tab. Orofer XT /OD

7. Syp. CREMAFFIN 10ml /H/S  at night

 

Pt was referred to NIMS for further evaluation and treatment 

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