A 45year old female with fever

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 MARCH 10,2022

This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.

K.TEJA SREE , ROLL NO:54 ,  9th SEM

CASE

A 45 old female came to the opd with chief complaints of 

fever since 10days

HOPI:
Patient was apparently asymptomatic 10 days back then she developed fever which was incidious in onset , high grade and non progressive.
 It was not associated with chills, rigors, cold and cough
No history of  loose stools, vomitings, body pains, burning micturition.
No SOB, pedal edema, decreased urine output 
She got admitted in local hospital and said there was low platelet count and referred to our hospital and got admitted in our hospital 
She took papaya leaf juice 2days back and she developed rashes over the tongue and lips.




PAST HISTORY:
. Not a known case ofDM, HTN, CAD, Asthma, TB.epilepsy

PERSONAL HISTORY :
Appetite: decreased
Diet : mixed
Bladder and bowel: Regular 
Micturition : normal
Sleep :adequate
No addictions
 
No significant family history.

GENERAL EXAMNATION:
Patient is c/c/c. 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedel edema.

VITALS:
  • temp: 99 F
  • PR: 80 bpm
  • RR: 18 cpm.
  • BP: 120/90 mmhg.





RESPIRATORY SYSTEM: 

Upper respiratory tract
O/E of oral cavity-
  • mouth opening norml
  • Single ulcer over left lip on right side
  • Multiple small reddish ulcers over the tongue
  • Buccal mucosa normal
O/E of nose-
  • DNS to right side present
  • External framework normal
O/E of neck
  • Right side 1B lymph nodes palpable , non tender
Lower respiratory tract:
  •  position of trachea - central
  •  normal vesicular breath sounds
  •  Bilateral air entry present 

Abdomen: soft and non-tender. 



CVS: S1,  S2 heard
          no thrills and murmurs.
CNS: Normal and intact

INVESTIGATIONS:
On 10/3/2022






  • NS1 IGM - POSITIVE 

LFT
  • TB-0.75mg/dl
  • DB-0.16mg/dl
  • SGOT-99*
  • SGPT-80*
  • ALO-201*
  • Albumin-3.4*
 
On 11/3/2022
  • Ultrasound 

  • ECG



  • Hb-12.1
  • TLC-2,300
  • PCV-36.1
  • Platelets-38,000
  • IMP: normocytic normochromic anemia

PROVISIONAL DIAGNOSIS 
  • DENGUE FEVER with thrombocytopenia 

TREATMENT 
10/3/2022
  • NS, RL @100ml/hr
  • Inj. PANTOP 40mg
  • Temperature charting 4th hourly
  • Inj.OPTINEURON 10mg in100ml
  • ZYTEE gel (tongue)
  • Inj. NEOMOL1gm IV
  • Tab. DOLO 650mg

11/3/2022
  • NS, RL @100ml/hr
  • Inj. PANTOP 40mg
  • Temperature charting 4th hourly
  • BO,HR Monitoring 4th hourly
  • Inj.OPTINEURON 10mg in100ml
  • ZYTEE gel (tongue)
  • Inj. NEOMOL1gm IV
  • Tab. DOLO 650mg
  • GRBS 12th hourly
  • Monitor features of clinical manifestations and postural hypotension
12/3/2022
  • NS, RL @100ml/hr
  • Inj. PANTOP 40mg
  • Temperature charting 4th hourly
  • BP,HR Monitoring 4th hourly
  • Inj.OPTINEURON 10mg in100ml
  • ZYTEE gel (tongue)
  • Inj. NEOMOL1gm IV
  • Tab. DOLO 650mg
  • GRBS 12th hourly
  • Monitor features of clinical manifestations and postural hypotension

13/3/2022
  • NS, RL @100ml/hr
  • Inj. PANTOP 40mg
  • Temperature charting 4th hourly
  • BP,HR Monitoring 4th hourly
  • Inj.OPTINEURON 10mg in100ml
  • ZYTEE gel (tongue)
  • Inj. NEOMOL1gm IV
  • Tab. DOLO 650mg
  • GRBS 12th hourly
  • Monitor features of clinical manifestations and postural hypotension
On 14/03/2022
  • Plenty of oral fluids
  • Inj. PANTOP 40mg
  • Temperature charting 4th hourly
  • Inj.Neurobion fortee 
  • ZYTEE gel (tongue)
  • Inj. Limcee 500mg
  • Tab. DOLO 650mg
  • Monitor features of bleeding manifestations 
Discharged on 14/03/2022





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