66 YEAR OLD FEMALE CAME TO THE CASUALITY WITH C/O FEVER, DECREASED APPETITE, NAUSEA AND GIDDINESS SINCE 1 WEEK

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"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 individual 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 on the comment"


December 14,2021

66 YEAR OLD FEMALE CAME TO THE CASUALITY WITH C/O FEVER, DECREASED APPETITE, NAUSEA AND GIDDINESS SINCE 1 WEEK


66 year old female came to the casuality with

 C/O:

- Fever since 1 week
- Decreased appetite since 1 week
- Nausea since 1 week
- Giddiness since 1 week

HOPI:

Patient was apparently asymptomatic 1 week back and then she developed fever which was continuous type, relieved on taking medication, not associated with chills and rigors.
H/O decreased appetite, nausea and giddiness since 1 week
No H/O Burning micturition, headache, cold
No H/O Bleeding manifestations

PAST HISTORY:

K/C/O HTN since 1 year
Not a K/C/O DM/Asthma/TB/Epilepsy/CAD/CVD

FAMILY HISTORY:

Not significant.

GENERAL EXAMINATION:

Patient was Conscious,Coherent,Cooperative
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema. 

VITALS:

Temp. - 98 F
PR - 82 bpm
RR - 16 cpm
BP - 110/70 mmHg
SpO2 - 99% @ RA


             





SYSTEMIC EXAMINATION:

CVS - S1S2 heard, No murmurs
RS - BAE +, Right side IAA Crepts+
CNS - NAD
P/A - Soft, Non tender

INVESTIGATIONS:


Hemogram:

Hb-12.4

TLC- 7, 500

N- 30

L- 66

MCV-77.6

MCH-26.7

RBC - 4.65

PC - 70,000


LFT:

TB-1.10

DB - 0.26

SGOT - 278

SGPT - 213

ALP -390

TP -6.2

A/b- 3.24

A/g -1.09


RFT:

Ur - 39

Cr - 1.2

BGT -A positive.


CHEST X-RAY


ECG



2D ECHO 




USG ABDOMEN:




PROVISIONAL DIAGNOSIS:

Viral Pyrexia with Thrombocytopenia secondary to Dengue NS1 Positive with K/C/O Hypertension. 

Soap Notes:

S :-
No fresh complaints.
Pain abdomen decreased.

O :-

BP - 140/90 mmhg
PR - 80 bpm
Temp - 98.2F
RR -15cpm
Spo2 - 99% at RA

A :-

VIRAL PYREXIA WITH THROMBOCYTOPENIA SECONDARY TO (DENGUE NS1 POSITIVE) L.KNOWN CASE OF HTN.

P :-

1) IVF NS,RL @ 100ML /HR
2) INJ PAN 40MG IV/OD
3) INJ OPTINEURON 1AMP IN 100ML NS IV/OD OVER 30 MIN
4) PLENTY OF ORAL FLUIDS
5) W/F BLEEDING MANIFESTATIONS
6) INJ ZOFER 4MG IV/SOS
7) TAB DOLO 650MG PO/SOS
8) INJ NEOMOL 1GM IV/SOS 
9) BP,PR MONITORING 4TH HOURLY
10) STRICT TEMPERATURE MONITORING 4TH HOURLY.






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