60 year old female with high grade fever,weakness since 10 days

 This is 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 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 comment box is welcome. 



 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.

Kota Hrithik Raj
Roll no 76

3/01/23

60 year old female patient who is a resident of pallipadu came with chief complaints of 
•Fever since 10 days
•Generalised weakness since 10 days
•Backache  since 10 days

History of presenting illness:

Patient was apparently asymptomatic 10 days back and then she developed high grade fever,sudden in onset, with chills and rigors , continuous,no evening rise of temperature

Patient complains of backache since 10 days , continuous which is insidious in onset ,dull aching type,non radiating,with no aggravating and relieving factors.
 
She also has complaints of body pains since 10  days for which she got medication from their local RMP but it is not subsided

As the symptoms didn't subside she went to a government hospital where she was diagnosed with low blood pressure and Decreased platelet and kept under observation.

As her condition doesnt improved she came to our hospital

Past History:
Patient has no similar complaints in the past 
No surgeries underwent into the past
Not a known case of  Diabetes mellitus, hypertension, coronary artery diesease,asthma, epilepsy, tuberculosis.

Personal History:

Patient takes mixed diet, 
appetite is decreased, 
Bladder  and bowel movement are  normal
Addictions: Patient consumes alcohol occasionally (1-2pegs).
Patient smokes chutta since 40 years 1-2 per day.
Patient has no known allergies

Family History:

No significant family History

Treatment History:

Antipyretics , Antibiotics (unknown)

General Examination

Patient is conscious coherent coopertive well built and well nourished.

Vitals: 

Temperature: afebrile
BP- 90/70 mmHg
Pulse-80 beats per minute 
RR- 15 cpm

Pallor- present

Icterus :Absent
Cyanosis- absent
Lymphadenopathy-absent
Clubbing-absent
Generalised edema- absent
Bilateral pedal edema - seen
Systemic Examination:

Abdominal Examination -

On Inspection: 
Abdominal Distension is present 
Umbilcus is at centre (slit like) 
No dilated veins
No scars,sinuses.



Palpation:
No local rise in temperature
Tenderness is elicited in the Right Hypochondrium .
No visible pulsations
No organomegaly

Percussion: No Significant Findings

Auscultation:
Bowel sounds heard

Cardiovascular system:
S1 S2 heard ,no murmurs

Respiratory system:
Bilateral Air entry present
Normal vesicular breath sounds heard 

Central Nervous system:
Higher mental function intact 
No focal neurological deficit 

Provisional Diagnosis:
Dengue shock syndrome with Thrombocytopenia , Acute Kidney injury ,Acute Liver injury.

Investigations:
Fever chart
Hemogram:

Dengue test:
ECG:

Liver function tests:
1/1/23


2/1/23

Serum electrolytes:
1/1/23
2/1/23
3/1/23

Serum creatinine:
1/1/23


2/1/23
Blood urea:
1/1/23

2/1/23



 
Treatment:

IV fluids -Normal saline with 1 ampoule of optineuron 

-Injection Noradr 2 ampoules in 46 ml NS

Inj PAN 40mgIV/OD

Tab PCM PO/TID

Inj Neomol .


SOAP Notes On 03/01/2023


S - 


Decreased appetite

No fever spikes

Stools passed


O-

Pulse - 96 bpm 

BP - 80/50 mmhg on norad 4ml/hr

RR - 32cpm

SPO2- 97 % AT RA

TEMP - AFEBRILE


CVS - S1 , S2 +


RS - BAE + , NVBS


PA - SOFT , NT.

         NO ORGANOMEGALY 

CNS - NAD


INPUT - 4850

OUTPUT-4300


HAEMOGRAM:


         Hb – 9.7 gm/dl

         TLC – 6700cells/cu mm

         PLC - 16000



RENAL FUNCTION TESTS :

         Sodium : 140 mEq/L

         Potassium : 6.6 mEq/L

         Chloride : 105mEq/L



A- 

DENGUE SHOCK SYNDROME WITH THROMBOCYTOPENIA WITH AKI ( PRE RENAL -NON OLIGURIC) WITH ACUTE LIVER INJURY 



P-


IVF - 1 NS With 1 Ampoule of optineuron 100 ml/hr

IVF Normal saline ,ringers lactate@ 150 ml /hour 

Inj Noradr -2 ampoules in 46 ml NS @4 ml/hr

Inj Lasix 20 mg IV OD ( IF SBP >110 mmhg)


Tab Doxy 100 mg PO/BD


Monitor vitals 4th hrly

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