A 45 yr old female with fever, vomiting

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 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.


I have been given this case to solve 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.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.



A  45 yr old female house wife came to casuality with cheif complaints of fever since 4 days, vomitings since 4 days


Patient was apparently asymptomatic 4 days back the developed fever low grade , intermittent type

Relieved on medication

Associated with chills and rigor , no diurnal variation


Vomitings sonce 4 days non projectile,  non bilious , not associated with pain abdomen


Past history

No h/ o DM, HTN, asthma , TB, epilepsy


Personal history 

She is married 

Mixed diet, normal appetite

Adequate sleep, bowel bladder movements are regular, normalno addictions


Family history - not significant


General examination

Pt c/c/c 

Vitals- 

Temperature- 100 F

BP- 110/80mmhg

Pr- 80 bpm


Systemic examination

Cvs- s1, s2 heard

Rs- BAE+, NVBS

P/A- soft, non tender

CNS- intact


Provisional diagnosis:

Dengue fever( NS1 POSITIVE)

Ecg



Chest x ray



Usg abdomen







Investigations

Hemogram at time of admission

Hb- 16.9

Tlc-2,500

Rbc-5.20

Plt-55,000

Serum urea- 21

Serum creatinine-0.9

Na+ 137

K+ 4.8

Cl- 99

LFT

TB- 0.39

DB- 0.16

AST- 108

ALT- 80

ALP- 169

TP- 5.6

ALB- 3.5

A/G- 1.72

RBS-205

STOOL FOR OCCULT BLOOD - POSITIVE


Hemogram 28/9/21  mrng 

Hb- 13.7

Tlc- 4,300

Rbc-5.10

Plt- 65,000



Treatment given

Day 1

1) IVF ( NS, RL)

2) INJ PAN 40 mg IV/ OD

3) INJ ZOFER 4 mg IV/ BD

4)TAB PCM 650 mg PO/ SOS

5) INJ BUSCOPAN  1 amp IV/ SOS

6) watch for bleeding manifestations

7) Vitals monitoring every 6 th hrly


Day 2

Treatment given

1) IVF ( NS, RL)

2) INJ PAN 40 mg IV/ OD

3) INJ ZOFER 4 mg IV/ BD

4)TAB PCM 650 mg PO/ SOS

5) INJ BUSCOPAN  1 amp IV/ SOS

6) watch for bleeding manifestations

7) Vitals monitoring every 6 th hrly


Discharge summary:

Date- 29/09/21

Ward- gm

Unit- 1

Treating faculty:

Dr valli( intern)

Dr akshitha( intern)

Dr tejaswini( intern)

Dr roshna( intern)

Dr kusuma( intern)

Dr raveen( pgy1)

Dr k vaishnavi( pgy3)

Dr nikhitha( pgy3)

Dr hareen( sr)

Dr arjun( ap)

Dr rakesh biswas( hod)

Diagnosis:

Dengue fever( NS1 POSITIVE)


Clinical history, findings:

  A 45 yr old female house wife came to casuality with cheif complaints of fever since 4 days, vomitings since 4 days


Patient was apparently asymptomatic 4 days back the developed fever low grade , intermittent type

Relieved on medication

Associated with chills and rigor , no diurnal variation


Vomitings sonce 4 days non projectile,  non bilious , not associated with pain abdomen


Past history

No h/ o DM, HTN, asthma , TB, epilepsy


Personal history 

She is married 

Mixed diet, normal appetite

Adequate sleep, bowel bladder movements are regular, normalno addictions


Family history - not significant


General examination

Pt c/c/c 

Vitals- 

Temperature- 100 F

BP- 110/80mmhg

Pr- 80 bpm


Systemic examination

Cvs- s1, s2 heard

Rs- BAE+, NVBS

P/A- soft, non tender

CNS- intact


Investigations:

Chest x ray normal

Usg abdomen- grade1 fatty liver

Ecg - within normal limits


Treatment given:

Day 1

1) IVF ( NS, RL)

2) INJ PAN 40 mg IV/ OD

3) INJ ZOFER 4 mg IV/ BD

4)TAB PCM 650 mg PO/ SOS

5) INJ BUSCOPAN  1 amp IV/ SOS

6) watch for bleeding manifestations

7) Vitals monitoring every 6 th hrly

Day 2

1) IVF ( NS, RL)

2) INJ PAN 40 mg IV/ OD

3) INJ ZOFER 4 mg IV/ BD

4)TAB PCM 650 mg PO/ SOS

5) INJ BUSCOPAN  1 amp IV/ SOS

6) watch for bleeding manifestations

7) Vitals monitoring every 6 th hrly


Advice at discharge:

1) plenty of oral fluids

2) TAB . PANTOP 40 mg PO/ OD  before break fast for 5 days

3)TAB . LEVICITRIZENE 10 mg PO/ HS for 5 days

4) TAB. MVT PO/ OD at 2pm 

for 10 days


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