50 year female with fever, vomiting, Nausea

 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 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 50 year female resident of kodichedu came with 

 CHIEF COMPLAINTS :

- Fever since 10 days 

- Vomitings since 4-5 days

- Nausea from 3-4 days


HISTORY OF PRESENT ILLNESS :

- Patient was asymptomatic 10 days ago and developed fever which is high grade, continuous , associated with chills and rigors.

- She went to local hospital and was kept on symptomatic management and again revisited after 3 days as fever is not decreased then she was diagnosed Typhoid .

- Slowly the fever got subsided , then she developed vomitings after a day which was non projectile, non bilious, food as content for 4 days . So she again went to the hospital where she got to know her platelets count was decreased. She was referred to Kim's, Nkp.


PAST HISTORY :

Diabetes - Since 1 year stopped medication from 5 to 6 months

Hypertension - Since 1 year on medication ( unknown)

TB - No

Asthma - No

Epilepsy - No

CVD - No

Chemo/Radiation Exposure - No

Surgical history - No



FAMILY HISTORY : Nil significant 



PERSONEL HISTORY :

Diet - Mixed

Appetite - lost since 3-4 days

Bowel and bladder - Normal

Allergies - No

Addictions - No



GENERAL EXAMINATION :

Temperature - 99 °F

Pulse - 88 beats/min

BP - 130/80 mmHg

RR - 14 cycles/min

GRBS - 112 mg% 

SPO2 - 98 %


Pallor - No

Icterus - No

Clubbing - No

Cyanosis - No

Lymphadenopathy - No



SYSTEMIC EXAMINATION :


CVS :

No thrills

No murmurs

S1 and S2 heard


RESPIRATORY SYSTEM :

Position of trachea - Central

 Dyspnoea , Wheeze - Absent 

Breath Sounds - vesicular


ABDOMEN :

Shape - Scaphoid

No Tenderness

No palpable mass

Umbilicus inverted

Bowel sounds heard


CNS : Normal

- Patient is Consious, Coherent, Well oriented to time place and surroundings.



INVESTIGATIONS :

1/9/22 -


CBP -


Biochemistry report -


Widal test -



Intake output chart -


ECG -


Colour Doppler 2D -


USG -



Blood grouping and Rh typing -



Random blood sugar - 


NS 1 Antigen -


Haemogram -




LFT -



RFT -



2/9/22 -

Haemogram -


Intake output chart -




3/9/22 -

I / O : 2400 / 1850 ml

GRBS : 115 mg/dl 

FBS : 99 mg/dl 

Urea : 20 mg/dl 

Creatinine : 0.7 mg/dl

Na : 132 mEq / l 

Cl :  103 mEq / l

K : 40 mEq / l


01-09-2022

Diagnosis :  VIRAL PYREXIA 

Rx : 

1. IVF NS and RL @ 100ml/hr  

2. Inj. Pantop 40mg IV/OD 

3. Inj. Optineuron  1 amp + 100 ml NS IV OD 

4. Tab. Dolo 650 mg PO QID

5. Inj. Neomol 1gm IV SOS ( if temp > 101°F) 

6. Plenty of oral fluids

7. Watch for bleeding manifestation and postural hypotension


 02 - 09 - 2022 

Diagnosis :  DENGUE  NS 1 POSITIVE WITH THROMBOCYTOPENIA 

( No bleeding manifestation, no vomiting, no loose stools ) 

On examination : 

Pt is C/C/C 

BP : 130/80 mm of Hg

PR : 90 bpm 

CVS :  S1 and S2 heard 

RS : BAE present 

RR :  14 cpm 

CNS : NAD 

P/ A : Soft and non tender 

I / O : 2600 / 1600 ml

Rx :

1.1. IVF NS and RL @ 100ml/hr  

2. Inj. Pantop 40mg IV/OD 

3. Inj. Optineuron 1 amp in 100 ml NS/ IV/ OD 

4. Tab. Dolo 650 mg PO QID

5. Inj. Neomol 1gm IV SOS ( if temp > 101°F) 

6. Plenty of oral fluids

7. Watch for bleeding manifestation and postural hypotension

03 - 09 - 2022

Diagnosis : DENGUE NS 1 POSITIVE WITH THROMBOCYTOPENIA 

( No bleeding manifestation, no vomiting, no loose stools ) 

On examination : 

Pt is C/C/C 

BP : 120/70 mm of Hg

PR : 80 bpm 

CVS : S1 and S2 heard 

RS : BAE present 

RR : 16 cpm 

CNS : NAD 

P/ A : Soft and non tender 

I / O : 2400 / 1850 ml

GRBS : 115 mg/dl 

FBS : 99 mg/dl 

Urea : 20 mg/dl 

Creatinine : 0.7 mg/dl

Na : 132 mEq / l 

Cl :  103 mEq / l

K : 40 mEq / l


Rx :

1.1. IVF NS and RL @ 100ml/hr  

2. Inj. Pantop 40mg IV/OD 

3. Inj. Optineuron 1 amp in 100 ml NS/ IV/ OD 

4. Tab. Dolo 650 mg PO QID

5. Inj. Neomol 1gm IV SOS ( if temp > 101°F) 

6. Plenty of oral fluids

7. Watch for bleeding manifestation and postural hypotension


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