A 34year old female with fever

SUDHAMSHI REDDY M

MBBS 9th semester

Roll no:80

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’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 .

Following is the view of my case..

A 34 year old female presented to the OPD with chief complaints of 

Fever since 2 days

HISTORY OF PRESENTING ILLNESS :

The patient was apparently asymptomatic 2 days back, when she developed 

Fever which was sudden in onset , intermittent in nature, associated with chills.

Fever was more during the night.

It was associated with headache.

2-3 episodes of loose stools on the day of fever.

Fever subsided on taking medication

Not associated with cough, vomitings.

PAST HISTORY : 

History of pre-eclampsia for previous three pregnancies 

No history of DM ,TB , HTN, Asthma

No history of blood transfusions 

PERSONAL HISTORY:

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel and bladder movements: regular

Addictions: none

FAMILY HISTORY:

No history of similar complaints in the family.

No history of Diabetes, Tuberculosis, Stroke, Asthma, any other hereditary diseases in the family.

GENERAL EXAMINATION: 

The patient is examined in a well lit room, with informed consent

The patient is conscious, coherent, cooperative, is well oriented to time, place, person.

She is moderately built and nourished.

Pallor : absent

Icterus : absent

Cyanosis : absent

Clubbing : absent

Lymphadenopathy : absent

Edema : absent

VITALS

Temperature-98.5F

Heart rate-92 beats/min

Blood pressure-110/80 mmHg

Respiratory rate-18 cycles/min

SPO2-98% at room air

SYSTEMIC EXAMINATION:

CVS: S1 and S2 heard

         No added thrills, murmurs

RESPIRATORY SYSTEM: Normal vesicular breath sounds heard, position of trachea central, no adventious sounds heard, no dyspnea and wheeze

PER ABDOMEN: obese, non tender, no palpable mass, no free fluid, no organomegaly

   Hernial orifices : umbilical hernia

CENTRAL NERVOUS SYSTEM: 

Level of consciousness : conscious to time, place, person

Speech: normal

Cranial nerves -Normal

Motor and sensory: normal 

Reflexes 

                          Right             Left 

Biceps                 2+                   2+

Triceps                2+                   2+

Supinator           2+                   2+ 

Knee                    2+                   2+ 

Ankle                   2+                   2+                     

INVESTIGATIONS:

   COMPLETE BLOOD PICTURE       

     Platelet count:Day 1: 87,000/ cumm

                               Day 2: 65,000/ cumm

     Total leukocyte count:Day 1: 2000cells/cumm

                                             Day 2: 2400 cells/cumm 

LIVER FUNCTION TESTS-   

Total bilirubin=0.6mg/dl

Direct bilirubin=0.20mg/dl

AST: 35 IU/L

ALT: 10 IU/L

ALP=182 IU/L

Albumin=3.1gm/dl

Total Protein:5.0

A/G Ratio=1.69

RENAL FUNCTION TESTS-

Urea: 21mg/dl
Creatinine: 0.8mg/dl

USG ABDOMEN :

          

PROVISIONAL DIAGNOSIS:

Viral pyrexia is with thrombocytopenia 

TREATMENT REGIMEN:

1. IVF NORMAL SALINE, RINGER LACTATE @100ml/hr

2. Inj PAN 40mg IV OD

3. Inj ZOFER 4mg IV 

4. Tab DOLO 650 TID

5. Inj NEOMOL 1mg IV