57 year old female with fever, chills and rigor

 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 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 57 YEAR OLD FEMALE WHO IS A RESIDENT OF YERRAVALLI CAME TO THE OPD WITH 

 CHIEF COMPLAINTS :

Vomitings since 5 days 1 episode per day

 Fever since 5 days

Chest pain on and off since 3 days

SOB since 1 day

Cough with sputum


HISTORY OF PRESENT ILLNESS :

- Patient was apparently normal 5 days ago, Then she developed fever with chills and rigors, Nausea and vomitings 1 episode per day ( Non projectile, Non bilious, Content is of food particles).

- Pricking type of Abdominal pain with no aggravating or relieving factors

- 2-3 episodes of watery stools per day

- She then developed chest pain since 3 days along with back pain

- From yesterday she is having SOB, Cough with sputum and whole body weakness.


PAST HISTORY :

Diabetes - No

Hypertension - Present since 1 year ( un known medication)

TB - No

Asthma - No

Epilepsy - No

CVD - No

Chemo/Radiation Exposure - No


Surgical history - Total abdominal hysterectomy 15 years ago


FAMILY HISTORY : Nil significant 


PERSONEL HISTORY :

Diet - Mixed

Appetite - Lost since 5 days

Bowel movements - Watery stools 

 Bladder movements - Normal

Allergies - No

Addictions - No


GENERAL EXAMINATION :

Temperature - 96.9 °F

Pulse - 90 beats/min

BP - 120/80 mmHg

RR - cycles/min

GRBS - mg%

SPO2 - 100 %


Pallor -

Icterus -

Clubbing -

Cyanosis -

Lymphadenopathy -


SYSTEMIC EXAMINATION :

CVS :

No thrills

No murmurs

S1 and S2 heard

SYSTEMIC EXAMINATION :

CVS :

No thrills

No murmurs

S1 and S2 heard


RESPIRATORY SYSTEM :

Position of trachea - Central

No Dyspnoea , Wheeze

Breath Sounds - vesicular


ABDOMEN :

Shape - Scaphoid

No Tenderness

No palpable mass

Umbilicus inverted

Bowel sounds heard


CNS : 

Patient is Consious, Coherent well oriented to time place and surroundings 




INVESTIGATIONS :












PROVISIONAL DIAGNOSIS :

DENGUE WITH SEVERE THROMBOCYTOPENIA 

TREATMENT :

- IV fluids NS

                RL @ 100ml/hr

- Inj Optineuron 1amp in 100 ml IV/OD

- Inj Pan 40 mg IV/OD

- Inj Zofer 4 mg IV /SOS

- TAB Dolo 650 mg TID

- Inj Doxy 100 mg IV/BD

- Inj Neomol 1mg IV/SOS

- Strict I/O Charting

- W/F Bleeding manifestation

- Monitor vitals and inform SOS


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