50 year female with fever, vomiting, Nausea

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I have been given this case 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 50 year female resident of kodichedu came with 

 CHIEF COMPLAINTS :

- Fever since 10 days 

- Vomitings since 4-5 days

- Nausea from 3-4 days

HISTORY OF PRESENT ILLNESS :

- Patient was asymptomatic 10 days ago and developed fever which is high grade, continuous , associated with chills and rigors.

- She went to local hospital and was kept on symptomatic management and again revisited after 3 days as fever is not decreased then she was diagnosed Typhoid .

- Slowly the fever got subsided , then she developed vomitings after a day which was non projectile, non bilious, food as content for 4 days . So she again went to the hospital where she got to know her platelets count was decreased. She was referred to Kim's, Nkp.

PAST HISTORY :

Diabetes - Since 1 year stopped medication from 5 to 6 months

Hypertension - Since 1 year on medication ( unknown)

TB - No

Asthma - No

Epilepsy - No

CVD - No

Chemo/Radiation Exposure - No

Surgical history - No

FAMILY HISTORY : Nil significant 

PERSONEL HISTORY :

Diet - Mixed

Appetite - lost since 3-4 days

Bowel and bladder - Normal

Allergies - No

Addictions - No

GENERAL EXAMINATION :

Temperature - 99 °F

Pulse - 88 beats/min

BP - 130/80 mmHg

RR - 14 cycles/min

GRBS - 112 mg%

SPO2 - 98 %

Pallor - No

Icterus - No

Clubbing - No

Cyanosis - No

Lymphadenopathy - No

SYSTEMIC EXAMINATION :

CVS :

No thrills

No murmurs

S1 and S2 heard

RESPIRATORY SYSTEM :

Position of trachea - Central

 Dyspnoea , Wheeze - Absent 

Breath Sounds - vesicular

ABDOMEN :

Shape - Scaphoid

No Tenderness

No palpable mass

Umbilicus inverted

Bowel sounds heard

CNS : Normal

- Patient is Consious, Coherent, Well oriented to time place and surroundings.

INVESTIGATIONS :

1/9/22 -

CBP -

Biochemistry report -

Widal test -

Intake output chart -

ECG -

Colour Doppler 2D -

USG -

Blood grouping and Rh typing -

Random blood sugar - 

NS 1 Antigen -

Haemogram -

LFT -

RFT -

2/9/22 -

Haemogram -

Intake output chart -

3/9/22 -

I / O : 2400 / 1850 ml

GRBS : 115 mg/dl 

FBS : 99 mg/dl 

Urea : 20 mg/dl 

Creatinine : 0.7 mg/dl

Na : 132 mEq / l 

Cl :  103 mEq / l

K : 40 mEq / l

PROVISIONAL DIAGNOSIS :

Viral pyrexia

TREATMENT :

01-09-2022

Diagnosis : VIRAL PYREXIA 

Rx : 

1. IVF NS and RL @ 100ml/hr  

2. Inj. Pantop 40mg IV/OD 

3. Inj. Optineuron 1 amp + 100 ml NS IV OD 

4. Tab. Dolo 650 mg PO QID

5. Inj. Neomol 1gm IV SOS ( if temp > 101°F) 

6. Plenty of oral fluids

7. Watch for bleeding manifestation and postural hypotension

02 - 09 - 2022 

Diagnosis : DENGUE NS 1 POSITIVE WITH THROMBOCYTOPENIA 

( No bleeding manifestation, no vomiting, no loose stools ) 

On examination : 

Pt is C/C/C 

BP : 130/80 mm of Hg

PR : 90 bpm 

CVS : S1 and S2 heard 

RS : BAE present 

RR : 14 cpm 

CNS : NAD 

P/ A : Soft and non tender 

I / O : 2600 / 1600 ml

Rx :

1.1. IVF NS and RL @ 100ml/hr  

2. Inj. Pantop 40mg IV/OD 

3. Inj. Optineuron 1 amp in 100 ml NS/ IV/ OD 

4. Tab. Dolo 650 mg PO QID

5. Inj. Neomol 1gm IV SOS ( if temp > 101°F) 

6. Plenty of oral fluids

7. Watch for bleeding manifestation and postural hypotension

03 - 09 - 2022

Diagnosis : DENGUE NS 1 POSITIVE WITH THROMBOCYTOPENIA 

( No bleeding manifestation, no vomiting, no loose stools ) 

On examination : 

Pt is C/C/C 

BP : 120/70 mm of Hg

PR : 80 bpm 

CVS : S1 and S2 heard 

RS : BAE present 

RR : 16 cpm 

CNS : NAD 

P/ A : Soft and non tender 

Rx :

1.1. IVF NS and RL @ 100ml/hr  

2. Inj. Pantop 40mg IV/OD 

3. Inj. Optineuron 1 amp in 100 ml NS/ IV/ OD 

4. Tab. Dolo 650 mg PO QID

5. Inj. Neomol 1gm IV SOS ( if temp > 101°F) 

6. Plenty of oral fluids

7. Watch for bleeding manifestation and postural hypotension