A 57 Year old female presented with Nausea, vomitings,. Fever , SOB

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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 57 YEAR OLD FEMALE WHO IS A RESIDENT OF YERRAVALLI CAME TO THE OPD WITH 

 CHIEF COMPLAINTS :

Vomitings since 5 days 1 episode per day

 Fever since 5 days

Chest pain on and off since 3 days

SOB since 1 day

Cough with sputum

HISTORY OF PRESENT ILLNESS :

- Patient was apparently normal 5 days ago, Then she developed fever with chills and rigors, Nausea and vomitings 1 episode per day ( Non projectile, Non bilious, Content is of food particles).

- Pricking type of Abdominal pain with no aggravating or relieving factors

- 2-3 episodes of watery stools per day

- She then developed chest pain since 3 days along with back pain

- From yesterday she is having SOB, Cough with sputum and whole body weakness.

PAST HISTORY :

Diabetes - No

Hypertension - Present since 1 year ( un known medication)

TB - No

Asthma - No

Epilepsy - No

CVD - No

Chemo/Radiation Exposure - No

Surgical history - Total abdominal hysterectomy 15 years ago

FAMILY HISTORY : Nil significant 

PERSONEL HISTORY :

Diet - Mixed

Appetite - Lost since 5 days

Bowel movements - Watery stools 

 Bladder movements - Normal

Allergies - No

Addictions - No

GENERAL EXAMINATION :

Temperature - 96.9 °F

Pulse - 90 beats/min

BP - 120/80 mmHg

RR - cycles/min

GRBS - mg%

SPO2 - 100 %

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

No Dyspnoea , Wheeze

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 -

Serum Creatinine:

LFT :

Random blood sugar :

Blood grouping and Rh typing :

Haemogram:

Timely recording: 

USG :

Serum Electrolytes:

PROVISIONAL DIAGNOSIS :

Dengue with severe thrombocytopenia 

TREATMENT :

- IV fluids NS

                RL @ 100ml/hr

- Inj Optineuron 1amp in 100 ml IV/OD

- Inj Pan 40 mg IV/OD

- Inj Zofer 4 mg IV /SOS

- TAB Dolo 650 mg TID

- Inj Doxy 100 mg IV/BD

- Inj Neomol 1mg IV/SOS

- Strict I/O Charting

- W/F Bleeding manifestation

- Monitor vitals and inform SOS