A 45 year old female with Fever a/w chills

 

20 August 2022

Santhoshini 

2k18 batch (Roll no.82)

This is an a 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.

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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.

A 45 year old female patient who is a farmer by occupation came with chief complaints of fever associated with chills since 10 days , headache since 10 days , generalised  body pains since 10 days , SOB since 5 days , decreased appetite since 3 days.

HOPI

Patient was apparently asymptomatic 10 days back then she developed fever a/w chills which was intermittent in nature , relieved temporarily on medication and was a/w headache, Generalised body pains. Since 5 days patient had complaints of SOB on exertion which gradually progressed to grade 2/3.

There is no H/O chest pain , palpitations,  syncope attacks.

There is no H/O pedal edema , burning micturition and decreased urine output.

No signs of any bleeding manifestations.

PATIENT'S DAILY ROUTINE 

Patient is a farmer by occupation and wakes up early in the morning cooks food and goes to work.

PAST HISTORY 

Patient is N/K/C/O Diabetes, Hypertension, TB, Asthma , Thyroid disorders , CAD and CVD.

TREATMENT HISTORY 

Not significant 

PERSONAL HISTORY 

Diet - Mixed                                                    

Appetite- Decreased                                            

Bowel and bladder habits - Regular                     

No known allergies                                    

Addictions - No

FAMILY HISTORY 

Not significant 

GENERAL EXAMINATION 

Patient is conscious,  coherent and cooperative. Well oriented to time,  place and person. Moderately built and nourished.                    

Pallor - Absent                                                    

Icterus - Absent                                                    

Cyanosis - Absent                                          

Clubbing- Absent                        

Lymphadenopathy- Absent                            

Edema - Absent 

             Lt

             Rt

VITALS 

Temp - 98°F                                                                

PR - 99bpm                                                                

BP- 110/70mmHg                                                     

RR- 30Cpm

SYSTEMIC EXAMINATION 

RESPIRATORY SYSTEM                                        

BAE- Present                                                      

Normal vesicular breath sounds- Heard

CVS                                                                               

S1 and S2- Heard                                                     

No Murmurs 

GIT - Soft and Non tender Abdomen

CNS - No focal Neurological deficits

INVESTIGATIONS

 

PROVISIONAL DIAGNOSIS 

 

Dengue with thrombocytopenia with   polyserositis.

TREATMENT 

IV fluids - 20 NS and 20 RL@50ml/hr

Inj. Neomol 1gm IV

Tab. Dolo 650mg Per Oral