A 60 year old female with high gade fever and weakness since 12days
Jan 6 2023
This is 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 patients 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 comment box is welcome.
55 year old female resident of pallipadu presented with chief compliants of:
-Fever since 10 days
-Generalised Weakness since 10 days
-Backache since 10 days
-Swelling in legs since 2 days
History of presenting Illness:
Patient was apparently asymptomatic 12 days back then she developed fever which is sudden in onset, continuous, with chills and no rigor ,no evening rise of temperature.
Patient complains of backache since 12 days , continuous which is insidious in onset,pain is confined to shoulder mostly ,dull aching type,non radiating,with no aggravating and relieving factors.
Patient complains of Generalised Weakness since 12 days
Patient went to RMP doctor ,used medicines for 2 days which didn't subside ,so they went to Nalgonda government hospital and was diagnosed with dengue and low platelet count ,medicines were taken for 3 days which gave no relief
Patient went to miryalaguda hospital on 28 December , got admitted and came to KIMS for further management .
Past History:
Patient has no similar complaints in the past
No history of Diabetes mellitus, hypertension,asthma, epilepsy, tuberculosis.
Personal History:
Patient takes mixed diet, appetite is decreased, bladder movement is normal, patient complains of decreased bowel movements.
Addictions: Patient consumes alcohol occasionally (1-2pegs).
Patient smokes chutta since 40 years 1-2 per day.
Patient has no known allergies
Family History:
No significant family History
Treatment History:
Antipyretics , Antibiotics (unknown)
General Examination
Patient is conscious coherent coopertive well oriented to time, place and person. She is well built and well nourished.
Icterus- present 
Cyanosis - Absent
Clubbing - Absent
Generalised Lymphadenopathy- Absent
Bilateral Pedal Edema is present.
Vitals:
Temperature:febrile
BP- 110/70 mmHg
Pulse-81 beats per minute
RR- 16
Systemic Examination:
Abdominal Examination -
On Inspection:
Abdominal Distension is present
Umbilcus is at centre (slit like) No dilated veins,No scars,sinuses.
Palpation:
No local rise in temperature
Tenderness is present in the Right Hypochondrium .
No visible pulsations
No palpable mass
Percussion:
No shifting dullness
Auscultation:
Bowel sounds heard
Cardiovascular system:
S1 S2 heard ,no murmurs
Respiratory system:
Bilateral Air entry present
Normal vesicular breath sounds heard
Central Nervous system:
Higher mental function intact
No focal neurological deficit
Investigations:
1-01-23
2-1-23
4-01-23
4-01-23
6-01-23
Platelets
On 31/12/22-26000/mm3
1/1/23-22000/mm3
2/1/23-28000/mm3
3/1/23- 16000/mm3
4/1/23-26000/mm3
5/1/23-25000/mm3
6/1/23-64000/mm3
PROVISIONAL DIAGNOSIS
Dengue fever with Thrombocytopenia with Acute Kidney injury ,Acute Liver injury.
Treatment:
IV fluids -Normal saline with 1 ampoule of optineuron
-Injection Noradr 2 ampoules in 46 ml NS
Inj PAN 40mgIV/OD
Tab PCM PO/TID
Inj Neomol .
Comments
Post a Comment