60 year old female with fever, backache and generalised weakness.
Jan 3 2023
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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.
60 year old female was admitted to opd with chief complaints of
1.Fever since 10 Days
2.Backache since 10days
3.Generalised weakness since 10 days
History of presenting illness:—
Patient was apparently asymptomatic 10 days ago.Then she developed high grade fever which was sudden in onset , continuous without diurnal variation and associated with chills.
She even complained of backache since 10 days which is insidious in onset , gradually progressive and persistent , dull aching and non radiating pain.
She even complained of generalized weakness since 10 days. and devoleped bilateral pedal edema.
Then she went to govt hospital where she was diagnosed with low blood pressure and decreased platelets.
As her condition was not improving she was admitted in our hospital.
Past history:
Not a known case of Diabetes, Hypertension, Asthma ,TB, epilepsy and thyroid disorders.
No history of previous surgeries.
Personal history:
Diet : Mixed
Appetite: decreased
Sleep: disturbed
Bowel and bladder movements : Regular
History of smoking 2 to 3 times a day since 40 yrs (chutta).
Family history:
No significant family history
Treatment history:— antipyretic and antibiotics (unknown).
General examination:
Patient is conscious coherent and cooperative
Moderately built and nourished
Well orientated to time place and person
Pallor - present
Icterus - absent
Cyanosis- absent
Clubbing- absent
Lymphadenopathy - absent
Pedal edema - pesent
Vitals:
Temperature : afebrile
BP: 80/60 mm hg
Pulse: 90 bpm
RR: 30cpm
Systemic examination:
Abdominal examination:
Inspection:
On inspection abdomen is slightly distended, no flank fullness, umbilicus is centre and slit like.No scars seen.No engorged veins
Palpation:
All inspectory findings are confirmed.
Tenderness is seen on the right hypochondrium region.
Percussion:
No significant findings
Auscultation:
Bowel sounds heard
CVS: S1 S2 heard
Respiratory system : Bilateral air entry present Normal vesicular breath sounds
CNS: No focal neurological deficits
Provisional diagnosis:— Dengue shock syndrome with thrombocytopenia , Acute kidney injury and Acute liver injury.
Investigations:—
Fever chart:—
On 31-12-22 —26,000
on 1|1|2023–22,000
On 1/1|2023 (evening) - 28,000
On 2-1-23 — 16000
3-1-21– 26000
Treatment:—
IV fluids-normal saline with 1 ampoule of optineurin
Inj. Noradrenaline 2ampoules in 46ml od normal saline.
Inj PAN 40mg IV
Tab PCM per oral TID
inj . Neomal.
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