A 21 yr old female with pyrexia and vomitings


 

July 26, 2022
Medical case disscussion 


July 23,2022

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent

Here we discuss our patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

This E log book also reflects my patient - centered online learning  portfolio and your valuable inputs inthe comment box are welcome.
Name : Jyothi Reddy 

Roll no : 44
I have been given this case to solve an attempt to understand the topic of "patient clinical analysis data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan

        CASE DISCUSSION
A 21 year old female patient from Islamilpalli, who's a Bsc nursing student came to the casuality with chief complaints of  
•Fever since 10am on 21/7/22
•Body pains
•Vomitings since 21/7/22 evening
•History on non-productive cough

HOPI :
A 21 year old female patients presenting with fever,insidious in onset,high grade,continous,associated with chills&body pain since 10 am 21/7/22

Vomitings on 21/7/22 evening 6 episodes , non bilious type,non-projectile, food particles and water as content,was associated with abdominal pain(h/o Outside food intake - corn,chicken on 20/7/22)


No H/o loose stools



No H/o cold,burning micturation,ear ache,tinnitus,shortness of breath,chest pain,palpitations,diarrhoea,eye pain



Daily routine :


 Wakes up at 7 am,do her regular activities,have breakfast and attend college classes,clinicals,have lunch at 1pm and attend college from 2-4pm , and having snacks on road side frequently, goes to bed at 10pm



Past history : 


Not a k/c/o diabetes/ hypertension/asthma/CAD/CVA/Epilepsy/Typhoid/Thyroid disorders


No previous surgical history.



Personal history :


•Diet : mixed


•Appetite :  decreased since yesterday


•Sleep :  distributed sleep because of chills and rigor



•Bowel  movements :

Vomitings since yesterday evening

•Bladder movements: Regular

•Addictions : None

 

Allergies :

 Allergic to potato , Roselle leaves and brinjal


Family history : not significant


Menstrual history : 

 Age of menarche : 12

 Duration of mensuration : 5 days

 LMP : 25/6/22

 Regular : 5/30

 No other Gynecologic problems


Immunization status : 

Vaccinated up to date

 Vaccinated for covid -19


      GENERAL EXAMINATION  •Patient is examined in a well lit room after obtaining consent

•Patient is conscious, coherent, cooperative.

 Well built and well nourished. 

 •Height -5'2

 • Weight - 55 kgs

•Pallor , Icterus,clubbing, cyanosis, koilonychia, edema are absent



•VITALS 


Temp- Afebrile (100 f) 


Bp-100/80 mm hg


PR- 84bpm


RR-16CPM


Spo2- 99% on RA


GRBS : 102




              SYSTEMIC EXAMINATION 



RS- bilateral air entry present 



CVS : S1, S2 + no murmurs 



P/A- soft and non tender


bowel sounds present 


CNS : No focal neurological defeicit 

HMF intact 

Power in B/L upper and lower limb Is 5

Reflexes are present with B/L plantars and flexors


INVESTIGATIONS : 

                                On 22/7/22

           Aptt
Haemogram 

Complete urine examination 






Bleeding and clotting time

Chest x-ray



ECG
 



Petichiae on palate


PROVISIONAL DIAGNOSIS : 

 • DENGUE WITH THROMBOCYTOPENIA AND LEUCOPENIA


*TREATMENT :

✓ Plenty of  oral fluids 

✓IVF ( NORMAL SALINE , RINGER LACTATE )

75 ml / hr 

✓ Inj Xone 1gm IV /BD

✓Inj Mifenac  MR PO / BD

✓Tablet okacet PO/BD 

✓Tablet Doxy 100mg/PO/BD 

✓Tablet metaspas PO / BD

✓Inj Neomol IV /SOS

✓ Tablet PCM 600 mg PO / TID 



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