25 yr old female with fever and thrombocytopenia









5th sep 2022

This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from an available global online community of experts to solve those patients 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 on the comment box are welcome.

 

I’ve 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.


Date of admn:- 3-9-22


Chief complaints :

A 25-year-old female patient came to the casualty with the cheif complaints of fever associated with headache since 5 days.
Loose stools since 2 days

History of present illness : patient was apparently asymtomatic 5 days back ,she went to her village on friday and got bitten by mosquitoes. Then she developed fever.


H/o Fever-
Onset - insidious
Duration- since 5 days
Type - intermittant ,high grade  
It was relieving on taking medications .
 Associated with chills and rigors.
Associated with generalised body aches and weakness
Diurnal variation absent
No increased temperature at night

H/0 loose stools-
Onset - sudden
Duration- 2 days
No.of episodes -5-8 episodes per day
Consistency- semi solid
Volume - small
Colour - black
Non foul smelling

H/0 pain in the epigastric region 
Aggravated on movements

— On 2nd sep morning, she went to a local lab at nalgonda and got her reports done which showed,
At 12:00 pm
1. Low platelet count- 72,000 lakhs 
Later she went to local hospital at nalgonda
At 2:00 pm
1.Low platelet count- 52,000 lakhs 
At 7:30 pm
1.Low platelet count- 35,000 lakhs 
At 8:00 am today
1.Low platelet count- 22,000 lakhs



Daily routine- wakes up at 7:00 am
            Breakfast at 9:00 am outside
           Goes to work -she works as dialysis worker
           Lunch at 12:00 pm
           Returns from work at 8:00 pm
           Takes rest, cooks, does dishes and other works
           Sleeps at 9:00 pm

Past history:—
Not a known case of, 
Hypertension, diabetes, epilepsy, CAD, asthma, thyroid.

Surgical history:— underwent appendectomy 8 yrs back (2014)

Personal history:—

Diet - mixed
Appetite - normal
sleep - adequate
Bowel and Bladder movements - normal micturition ,passing black coloured stools
Addictions - no
No known allergies

Drug history:—

Relieved on taking dolo

Family history:—

No significant family history

General examination:—

Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person at the time of examination.
She is moderately built and well nourished.
Pallor - absent
Icterus - absent
Cyanosis - absent 
Clubbing - absent
lymphadenopathy - absent
Pedal edema - absent











Vitals : on the day of admission (3/9/2022)

Temperature - afebrile
Pulse rate - 82 bpm
Respiratory rate - 16 cpm
Blood pressure - 110/90 mmHg
SpO2 - 99.6% on Room air
GRBS - 102 mg/dl

Systemic examination:—

CVS : S1 and S2 heart sounds heard
      NO murmurs and thrills
RESPIRATORY SYSTEM : Bilateral air entry present                            position of trachea - centrall
                        Vesicular breathsounds heard

CNS : no focal abnormal deficits
ABDOMEN :
Soft 
 On deep palpation - tenderness in epigastric region

              No palpable masses
              Bowel sounds heard 
              NO organomegaly

Fever chart:—


Investigations:—

On 3rd

SDP transfusion has been done on 3-9-22 at 11:25 pm


Today — 5th sep


MP strip test:—


NS1 antigen test:-






Provisional diagnosis:— Dengue with thrombocytopenia.

Treatment-

On day 1 (3-9-22)

1. IVF NS, RL@100ml / hr
2. INJ PAN 40 mg IV/OD
3. INJ. ZOFER 4mg IV/OD
4. TAB. DOXYCYCLINE 100 mg PO /BD
5.TAB. DOLO 650mg PO/SOS
6.TAB. OROFER- XT PO/ OD
7. INJ. OPTINEURON 1 AMP in 100 ml NS/ STAT
8.BP,PR,SpO2,GRBS, monitoring 4TH HOURLY


On day 2 (4-9-22)

1. IVF NS, RL@100ml / hr
2. INJ PAN 40 mg IV/OD
3. INJ. ZOFER 4mg IV/SOS
4. TAB. DOXYCYCLINE 100 mg PO /BD
5.TAB. DOLO 650mg PO/SOS
6.TAB. OROFER- XT PO/ OD
7. INJ. OPTINEURON 1 AMP in 100 ml NS/ STAT
8.BP,PR,SpO2,GRBS, monitoring 4TH HOURLY

On day 3 (5-9-22)

1. IVF NS, RL@100ml / hr
2. INJ PAN 40 mg IV/OD
3. INJ. ZOFER 4mg IV/SOS
4. TAB. DOXYCYCLINE 100 mg PO /BD
5. INJ. OPTINEURON 1 AMP in 100 ml NS/ IV/OD
6.TAB. OROFER-XT PO/OD
7.TAB.  DOLO 650mg PO SOS
8. Strict I/O charting
9.BP,PR,SpO2,GRBS,Temperature chart ing monitoring 4TH HOURLY











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