A 45 YR OLD FEMALE WITH FEVER

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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.

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UNIT 1 ADMISSION

A 45 yr old female pt came with cheif complaints of fever with chills since 3 days

Hopi - pt was apparently asymptomatic 3days back then she developed high grade fever associated with chills ,rigors

No c/o of cough, cold, 

No c/o of chestpain , palpitations,syncopal attacks

No c/o of sob , orthopnea ,pd

Nause present , no vomitigs,loose stools

No c/o of abd distention 

C/o of , burning micturition, decreased urine output 

No h/o HTN,, CVA, CAD,TB, epilepsy.

K/c/o dm since 2 yrs on regular medication 

Personal history:

Decreased appetite

Bowel and bladder movements are regular

Non alcoholic , non smoker 

The patient is conscious coherent and cooperative

Moderately built and moderately nourished. 

Vitals:

PR:80bpm

BP:110/80 mmHg

RR:16cpm

Spo2:99% at RA

GRBS: 560mg%

P/A: 

Shape of abdomen: scaphoid

Abdominal tenderness is present in epigastric region 

Hernial orifices- normal

No free fluid

Liver and spleen - not palpable

Bowel sounds are present

CVS: s1 ,s2 heard 

RS: vesicular breath sounds are heard 

CNS: normal 

Provisional diagnosis:

Viral pyrexia with thrombocytopenia ( Dengue)

INVESTIGATIONS:

Hemogram on 30/9/21

HB-14.7gm/dl

TLC- 5,600cells/cu.mm

RBC-5.67 million/cu.mm

PLT-40,000 lakhs/cu.mm

CUE:

Serum urea-43 mg/dl

Serum creatinine- 1.2 mg/dl

Serum electrolytes:

Na+: 134 meq/l

K+: 4.5 meq/l

Cl-: 96 meq/l

LFT

TB-0.93 mg/dl

DB-0.2 mg/dl

AST-107units/l

ALT-81 units/l

ALP-208 units/l

ALB-3.3gm /l

MALARIAN PARASITE - NEGATIVE

BLOOD GROUP- O POSITVE

NS1 ANTIGEN- POSITIVE( DENGUE)

 CHEST XRAY

ECG

ON 31/8/21

HB-13.4gm/l

TLC-6.700cells/cu.mm

RBC- 4.67million/cu.mm

PLT-45,000lakhs/cu.mm

FBS-357mg/dl    PLBS-324mg/dl

HBA1C- 78mg/dl

ON 1/9/21

HB-14.1gm/dl

TLC-9,600cells/cu.mm

RBC-4.96 million/cu.mm

PLT-35,000lakhs/cu.mm

ON 2/9/21

HB-12.8 gm/dl

TLC-6,800cells/cu.mm

RBC-4.48millions/cu.mm

PLT-70,000lakhs/cu.mm

ON 3/9/21

HB-13.1 gm/ dl

TLC-5,700 cells/ cu.mm

RBC- 4.60 millions/cu.mm

PLT- 80,000 lakhs/cu.mm

ON 4/9/21

HB-12.8 gm /dl

TLC-6,300cells/cu.mm

RBC-4.54 millions / cu.mm

PLT-1. 2 lakhs/cu.mm

TREATMENT GIVEN

Day-1

1)plenty of oral fluids

2) intravenous fluids(normal saline, ringer lactate 100ml/hr)

3) Inj PANTOP 40 mg  IV/ BD

4)Inj ZOFER 4mg IV/ TID

5) Inj HUMAN ACTRAPID INSULINS/C

8am- 1pm -8pm

6) vitals  monitoring

Day-2

1)plenty of oral fluids

2) intravenous fluids(normal saline, ringer lactate 100ml/hr)

3) Inj PANTOP 40 mg  IV/ BD

4)Inj ZOFER 4mg IV/ TID

5) Inj HUMAN ACTRAPID INSULINS/C

8am- 1pm -8pm

6) vitals  monitoring

Day-3

1)plenty of oral fluids

2) intravenous fluids(normal saline, ringer lactate 100ml/hr)

3) Inj PANTOP 40 mg  IV/ BD

4)Inj ZOFER 4mg IV/ TID

5) Inj HUMAN ACTRAPID INSULINS/C

8am- 1pm -8pm

6) vitals  monitoring

Day-4

1)plenty of oral fluids

2) intravenous fluids(normal saline, ringer lactate 100ml/hr)

3) Inj PANTOP 40 mg  IV/ BD

4)Inj ZOFER 4mg IV/ TID

5) Inj HUMAN ACTRAPID INSULINS/C

8am- 1pm -8pm

6) vitals  monitoring

Day-5

1)plenty of oral fluids

2) intravenous fluids(normal saline, ringer lactate 100ml/hr)

3) Inj PANTOP 40 mg  IV/ BD

4)Inj ZOFER 4mg IV/ TID

5) Inj HUMAN ACTRAPID INSULINS/C

8am- 1pm -8pm

6) vitals  monitoring

 

DISCHARGE SUMMARY:

patient came  to casuality with following history

Following examination was done

UNIT 1 ADMISSION

Dr. Aashitha

Dr. Vinay 

A 45 yr old female pt came with cheif complaints of fever with chills since 3 days

Hopi - pt was apparently asymptomatic 3days back then she developed high grade fever associated with chills ,rigors

No c/o of cough, cold, 

No c/o of chestpain , palpitations,syncopal attacks

No c/o of sob , orthopnea ,pd

Nause present , no vomitings,loose stools

No c/o of abd distention 

C/o of , burning micturition, decreased urine output 

No h/o HTN,, CVA, CAD,TB, epilepsy.

K/c/o dm since 2 yrs on regular medication 

Personal history:

Decreased appetite

Bowel and bladder movements are regular

Non alcoholic , non smoker 

The patient is conscious coherent and cooperative

Moderately built and moderately nourished. 

Vitals:

PR:80bpm

BP:110/80 mmHg

RR:16cpm

Spo2:99% at RA

GRBS: 560mg%

P/A: 

Shape of abdomen: scaphoid

Abdominal tenderness is present in epigastric region 

Hernial orifices- normal

No free fluid

Liver and spleen - not palpable

Bowel sounds are present

CVS: s1 ,s2 heard 

RS: vesicular breath sounds are heard 

CNS: normal 

Provisional diagnosis:

Viral pyrexia with thrombocytopenia (?  Dengue)

On giving following treatment

1)plenty of oral fluids

2) intravenous fluids(normal saline, ringer lactate 100ml/hr)

3) Inj PANTOP 40 mg  IV/ BD

4)Inj ZOFER 4mg IV/ TID

5) Inj HUMAN ACTRAPID INSULINS/C

8am- 1pm -8pm

6) vitals  monitoring

Patient platelet count gradually increased

On 30/8/21

PLT-40,000 lakhs/cu.mm

On 31/8/21

PLT-45,000lakhs/cu.mm

On 1/9/21

PLT-35,000lakhs/cu.mm

On 2/9/21

PLT-70,000lakhs/cu.mm

On 3/9/21

PLT- 80,000Lakhs/cu.mm

On 4/9/21

PLT-1.2 lakhs/cu.mm

As the platelet count increased and symptoms subsided she was planned to discharge on 4 /9/21