A 60 year old female with high grade fever and weakness since 10days
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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.
55 year old female resident of pallipadu presented with chief compliants of:
-Fever since 10 days
-Generalised Weakness since 10 days
-Backache since 10 days
-Swelling in legs since 2 days
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 10 days back then she developed FEVER which was sudden in onset, continuous, with chills and no rigor ,no evening rise of temperature.
Patient complains of BACKACHE since 10 days , continuous which is insidious in onset,pain is confined to shoulder mostly ,dull aching type,non radiating,with no aggravating and relieving factors.
She also has complaints of BODY PAINS since 10 days for which she got medication from their local RMP but it is not subsided
As the symptoms didn't subside she went to a government hospital where she was diagnosed with low blood pressure and Decreased platelet and kept under observation.
As her condition doesnt improved she came to our hospital .
The patient is now having Bilateral pedal edema , pitting type up to knee.
PAST HISTORY
Patient has no similar complaints in the past
No surgeries underwent into the past
No history of Diabetes mellitus, hypertension, coronary artery diesease,asthma, epilepsy, tuberculosis.
PERSONAL HISTORY
Patient takes mixed diet, appetite is decreased, bladder movement is normal, patient complains of decreased bowel movements.
Addictions: Patient consumes alcohol occasionally (1-2pegs).
Patient smokes chutta since 40 years 1-2 per day.
Patient has no known allergies
FAMILY HISTORY
No significant family History
TREAMENT HISTORY
Antipyretics , Antibiotics (unknown)
GENERAL EXAMINATION
Patient is conscious coherent coopertive well oriented to time, place and person. She is well built and well nourished.
Vitals:
Temperature: afebrile
BP- 90/70 mmHg
Pulse-80 beats per minute
RR- 15 cpm
Pallor : present
Icterus :Absent
Cyanosis- absent
Lymphadenopathy-absent
Clubbing-absent
Generalised edema- absent
Bilateral pedal edema - seen
SYSTEMIC EXAMINATION—ABDOMEN EXAMINATION
ON INSPECTION
Abdominal Distension is present
Umbilcus is at centre (slit like)
No dilated veins
No scars,sinuses.
ON PALPITATION
No local rise in temperature
Tenderness is elicited in the Right Hypochondrium .
No visible pulsations
No organomegaly
ON PERCUSSION
NO Significant findings
ON AUSCULTATION
Bowel sounds heard
CARDIOVASCULAR SYSTEM -
S1 S2 heard ,no murmurs
RESPIRATORY SYSTEM -
Bilateral Air entry present
Normal vesicular breath sounds heard
CENTRAL NERVOUS SYSTEM -
Higher mental function intact
No focal neurological deficit
PROVISIONAL DIAGNOSIS
Dengue shock syndrome with
Thrombocytopenia ,
Acute Kidney injury ,
Acute Liver injury.
INVESTIGATIONS
5/1/23
ECG
5/1/23
1/01/23
4/01/23
BLOOD UREA
1/1/23
2D echo report screening
Platelets:
On 31/12/22-26000/mm3
1/1/23-22000/mm3
2/1/23-28000/mm3
3/1/23- 16000/mm3
4/1/23-26000/mm3
31/12/22. 1/1/23. 2/1/23
SGOT levels. 127 123 128
SGPT Levels. 62 69 67
Alkaline phosphatase 682 843 915
IV fluids -Normal saline with 1 ampoule of optineuron
-Injection Noradr 2 ampoules in 46 ml NS
Inj PAN 40mgIV/OD
Tab PCM PO/TID
Inj Neomol .
4/1/2023
S - APPETITE IMPROVED
STOOLS PASSED
O-PULSE - 96 bpm , regular
BP - 110/80 mmhg on norad 2ml/hr
RR - 32 CPM
SPO2- 96 % AT RA
TEMP - AFEBRILE
CVS - S1 , S2 +
RS - BAE + , NVBS
PA - SOFT , NT. NO ORGANOMEGALY
CNS - NAD
INPUT - 3150 ml
OUTPUT-2900 ml
A- DENGUE SHOCK SYNDROME WITH THROMBOCYTOPENIA WITH AKI ( PRE RENAL -NON OLIGURIC) WITH ACUTE LIVER INJURY
WITH HYPERKALEMIA
P-IVF NS , RL ,DNS @ 100 ml /hour
INJ NORADR -2 ampoules IN 46 ml NS @2 ml/hr To taper according to MAP
TAB DOXY 100 mg PO/BD D3
MONITOR VITALS 4th HRLY in
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