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Case Discussion :
I have been given this case to solve in an order to 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 a Diagnosis and Treatment plan.
A 50 year old female came to the Hospital with the chief complaints of
* Fever since 1 week
* Loose stools since 3 days
* Vomitings since 1 day
History of present illness :
* Patient was apparently asymptomatic 1 week ago then she developed fever which of high grade associated with chills and rigors and continuous in nature and was taken to local hospital , investigation were done and was kept on symptomatic management and after 3 days, she revisited the hospital as her fever didn't subside following which some injection was given and they went home .
* Then he developed loose stools since 3 days and nausea and vomiting of 4 episodes yesterday evening which contained food particles , non - bilious.
* And then the fever got decreased and today morning she was taken to private hospital and got investigations done and found out that the platelets to be low and therefore referred to higher centre for further management.
History of Past Illness :
* No History of Similar Complaints in the Past.
* Known case of Hypertension since 1 year.
* Not a Known Case of DM, TB , Asthma, Epilepsy, Coronary Artery Disease.
Personal history:
Diet - Mixed
Appetite - Normal
Sleep - Adequate
Bowel movements - Regular
Bladder Movements - Regular
Addictions - None
Family History :
Not significant
Physical Examination :
A. General Examination
* Patient is conscious, coherent and co-operative and lying on the bed.
* He is well oriented to time, place and person.
* He is moderately nourished.
Pallor - Absent
Icterus - Absent
Clubbing - Absent
Cyanosis - Absent
Lymphadenopathy - Absent
Edema - Absent
Vitals:
Temperature - 99 F
Pulse Rate - 88 BPM
Blood Pressure - 130/80 mm Hg
Respiratory Rate - 14 CPM
SPO2 - 98 % at Room Air
Random Blood Sugar - 112 mg/dl
Systemic Examination :
CARDIOVASCULAR SYSTEM - S1 and S2 present, No murmurs
RESPIRATORY SYSTEM - BAE +, NVBS
PER ABDOMEN - Soft and Non tender, Scaphoid shaped abdomen ,
No free fluid ,
No palpable mass,
No organomegaly .
CENTRAL NERVOUS SYSTEM - E4V5M6, Moving all the four limbs against gravity.
Provisional Diagnosis :
Dengue NS1 positive with Thrombocytopenia
Treatment :
1. IV FLUIDS NS AND RL @ 100 ml/hr
2. INJ. PANTOP 40 mg IV /OD
3. INJ. OPTINEURON 1 amp in 100 ml NS /IV/OD
4. TAB. DOLO 650 mg /PO/QID
5. INJ. NEOMOL 1 gm /IV/SOS
6. PLENTY OF ORAL FLUIDS
7. WATCH FOR BLEEDING MANIFESTATIONS AND POSTIRAL HYPOTENSION
02/09/2022
S: complaints of fever, vomiting and loose stools subsided
O:
Patient is conscious,coherent and cooperative
BP - 130/80 mm Hg
PR - 90 bpm
RR- 14 cpm
Temp- Afebrile
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , non tender
CNS-NAD
I/O - 2600 ml/1600 ml
A : Dengue NS1 positive with Thrombocytopenia
P :
1. IV FLUIDS NS AND RL @ 100 ml/hr
2. INJ. PANTOP 40 mg IV /OD
3. INJ. OPTINEURON 1 amp in 100 ml NS /IV/OD
4. TAB. DOLO 650 mg /PO/QID
5. INJ. NEOMOL 1 gm /IV/SOS
6. PLENTY OF ORAL FLUIDS
7. WATCH FOR BLEEDING MANIFESTATIONS AND POSTIRAL HYPOTENSION
03/09/2022
S:
Complaints of Nausea
complaints of fever, vomiting and loose stools subsided
O:
Patient is conscious,coherent and cooperative
BP - 120/70 mm Hg
PR -76 bpm
RR- 16 cpm
Temp- Afebrile
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , non tender
CNS-NAD
I/O - 2450 ml/1800 ml
GRBS - 115 mg/dl
A : Dengue NS1 positive with Thrombocytopenia
P :
1. IV FLUIDS NS AND RL @ 100 ml/hr
2. INJ. PANTOP 40 mg IV /OD
3. INJ. OPTINEURON 1 amp in 100 ml NS /IV/OD
4. TAB. DOLO 650 mg /PO/QID
5. INJ. NEOMOL 1 gm /IV/SOS
6. PLENTY OF ORAL FLUIDS
7. WATCH FOR BLEEDING MANIFESTATIONS AND POSTIRAL HYPOTENSION
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