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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 41 year old female came to the OPD with the chief complaints of FEVER SINCE 1 WEEK AND BURNING MICTURITION SINCE 2 DAYS
HISTORY OF PRESENT ILLNESS:
* Patient was apparently asymptomatic 2 years ago then she developed blackish discoloration over the hands and face for which she sought for consultation and was diagnosed to be having DM and was on medication since then, and was asymptomatic till 6 months and then developed neck pains and headache for which she got her BP checked and was found to be high. Serial recordings of BP > 150 mmHg for 1 month and then started on antihypertensive.
* 1 week ago she developed fever which is of high grade associated with chills and rigors and not relieved on medication and associated with nausea.
* Had burning Micturition since 2 days
* Has Pain abdomen since evening
HISTORY OF PAST ILLNESS:
* Known case of DM and is on medication TAB. METFORMIN 500 MG/PO/OD
* Known case of HTN and is on medication TAB. AMLONG 5 MG /PO/OD + TAB. GLIMIPERIDE 1 MG
* No History of Similar Complaints in the Past.
* Not a Known Case of TB , Asthma, Epilepsy, Coronary Artery disease
PERSONAL HISTORY:
Diet - Mixed
Appetite - Normal
Sleep - Adequate
Bowel movements - Regular
Bladder Movements - Regular
Addictions - None
GENERAL EXAMINATION:
* Patient is conscious, coherent and co-operative and lying on the bed.
* She is well oriented to time, place and person.
* She is mildly nourished.
Pallor - Absent
Icterus - Absent
Clubbing - Absent
Cyanosis - Absent
Lymphadenopathy - Absent
Edema - Absent
VITALS AT THE TIME OF ADMISSION:
Temperature - 99.3 F
Pulse Rate - 88 BPM
Blood Pressure - 110/70 mm Hg
Respiratory Rate - 14 CPM
SPO2 - 98% at Room Air
SYSTEMIC EXAMINATION :;
CARDIOVASCULAR SYSTEM - S1 and S2 present, No murmurs
RESPIRATORY SYSTEM - BAE +, NVBS
PER ABDOMEN - Soft and TENDERNESS OF RIGHT HYPOCHONDRIAL, UMBILICAL , RIGHT LUMBAR and EPIGASTRIC REGION
CENTRAL NERVOUS SYSTEM - E4V5M6, HMF +
06/09/2022 :
08/09/2022 :
09/09/2022 :
Provisional Diagnosis :
Dengue NS1 positive with Thrombocytopenia
Treatment :
1. IV FLUIDS NS AND RL @ 100 ML/HR
2. INJ. NEOMOL 1GM / IV /SOS
3. INJ. PAN 40 MG /IV/ OD
4. INJ. ZOFER 4 MG / IV /SOS
5. TAB. PCM 650 MG / PO /QID
6. Plenty of oral fluids
7. TAB. METFORMIN 500 MG / PO/ OD
8. Temp charting 4th hourly
9. TAB. AMLONG 5 MG /PO/ OD
10/09/2022 :
S: Fever spikes subsided
O:
Patient is conscious,coherent and cooperative
BP - 100/70 mm Hg
PR - 84 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
A : Dengue NS1 positive with Thrombocytopenia
P:
1. IV FLUIDS NS AND RL @ 100 ML/HR
2. INJ. NEOMOL 1GM / IV /SOS
3. INJ. PAN 40 MG /IV/ OD
4. TAB. PCM 650 MG / PO /QID
5. Plenty of oral fluids
6. TAB. METFORMIN 500 MG / PO/ OD
7. Temp charting 4th hourly
8. TAB. AMLONG 5 MG /PO/ OD
11/09/2022 :
S: Fever spikes subsided
O:
Patient is conscious,coherent and cooperative
BP - 120/70 mm Hg
PR - bpm
RR- 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
A : Dengue NS1 positive with Thrombocytopenia
P:
1. IV FLUIDS NS AND RL @ 100 ML/HR
2. INJ. NEOMOL 1GM / IV /SOS
3. INJ. PAN 40 MG /IV/ OD
4. TAB. PCM 650 MG / PO /QID
5. Plenty of oral fluids
6. TAB. METFORMIN 500 MG / PO/ OD
7. Temp charting 4th hourly
8. TAB. AMLONG 5 MG /PO/ OD
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