July 23,2022
Hi all This is G Chaitanya ,,5th sem
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 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 inthe comment box are welcome.
I have been given this case to solve an attempt to understand the topic of "patient clinical analysis data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan
CASE DISCUSSION
A 21 year old female patient from Islamilpalli, who's a Bsc nursing student came to the casuality with chief complaints of
•Fever since 10am on 21/7/22
•Body pains
•Vomitings since 21/7/22 evening
•History on non-productive cough
HOPI :
A 21 year old female patients presenting with fever,insidious in onset,high grade,continous,associated with chills&body pain since 10 am 21/7/22
H/o Vomitings on 21/7/22 evening 6 episodes , non bilious type,non-projectile, food particles and water as content,was associated with abdominal pain(h/o Outside food intake - corn,chicken on 20/7/22)
No H/o loose stools
No H/o cold,burning micturation,ear ache,tinnitus,shortness of breath,chest pain,palpitations,diarrhoea,eye pain
Daily routine :
Wakes up at 7 am,do her regular activities,have breakfast and attend college classes,clinicals,have lunch at 1pm and attend college from 2-4pm , and having snacks on road side frequently, goes to bed at 10pm
Past history :
Not a k/c/o diabetes/ hypertension/asthma/CAD/CVA/Epilepsy/Typhoid/Thyroid disorders
No previous surgical history.
Personal history :
•Diet : mixed
•Appetite : decreased since yesterday
•Sleep : distributed sleep because of chills and rigor
•Bowel movements :
Vomitings since yesterday evening
•Bladder movements: Regular
•Addictions : None
Allergies :
Allergic to potato , Roselle leaves and brinjal
Family history : not significant
Menstrual history :
Age of menarche : 12
Duration of mensuration : 5 days
LMP : 25/6/22
Regular : 5/30
No other Gynecologic problems
Immunization status :
Vaccinated up to date
Vaccinated for covid -19
GENERAL EXAMINATION •Patient is examined in a well lit room after obtaining consent
•Patient is conscious, coherent, cooperative.
Well built and well nourished.
•Height -5'2
• Weight - 55 kgs
•Pallor , Icterus,clubbing, cyanosis, koilonychia, edema are absent
•VITALS
Temp- Afebrile (100 f)
Bp-100/80 mm hg
PR- 84bpm
RR-16CPM
Spo2- 99% on RA
GRBS : 102
SYSTEMIC EXAMINATION
RS- bilateral air entry present
CVS : S1, S2 + no murmurs
P/A- soft and non tender
bowel sounds present
CNS : No focal neurological defeicit
HMF intact
Power in B/L upper and lower limb Is 5
Reflexes are present with B/L plantars and flexors
INVESTIGATIONS :
On 22/7/22
*COMPLETE URINE EXAMINATION :
*APTT
*BLEEDING AND CLOTTING TIME
*BLOOD FOR M.P.-STRIP TEST
*BLOOD GROUPING AND Rh TYPING
*Fever chart showing continuous type of fever.
*
ECG* RASH
"On 23/7/22"
*USG Report
*Record of Temp,BP,RR &SPO2
"On 24/7/22"
*Haemogram
6 : 30 am
"On 25/7/22"
*Hemogram
(9 am)
(7pm)
*Record of Temparature,BP, RR AND SPO2
*USG Abdomen
"On 26/7/22"
*Haemogram
*Blood Urea
*Serum Creatinine
*Serum electrolytes & Serum Iodized Calcium
*Fever chart
* Investigation chart
"On 27/7/22"
*Haemogram
No fever spikes since yesterday
C/o pain in abdomen (subsided)
Pt is c/c/c
Bp:-110/60 mm hg
Pr:- 72 bpm
Spo2:-98%
Cvs:-s1 s2 +
R/s:- Blae +
P/a:- soft , tenderness over right hypochondrium
Cns:-Nad
Tlc:-4000 cells/cumm
Platelets:-70000 /cumm
Treatment on 27/7/22
-iv.fluids @75ml/hr -Ns,Rl
-inj.Neomol 100ml/iv/sos
-tab. Pan 40mg/po/od
-inj.tramadol 1amp/iv/sos
*Clinical Images
*Chest X-ray PA view
*Palate showing petechiae
COURSE IN THE HOSPITAL:
A 21 year female presented to the casuality with above mentioned complaints. Upon admission initial examination was done, Hess test was negative; No postural drop; Necessary investigations were done. Dengue for NS1 Ag was positive with negative IgM and IgG; TLC 4800 and Platelets 1.3 L. She was started on IVF and advised to drink plenty of oral fluids. On day 2; she c/o body pains, started having menses associated with Dysmenorrhoea; abdominal pain was decreased; Oral Mefenamic acid was started and IVF and NEOMOL were continued. USG Abdomen was done, which showed no sonological abnormality. On day 3; she had c/o dry cough, headache, Dysmenorrhoea and along with fever spikes. Urine and Blood were sent for Culture and sensitivity. Upon examination postural drop was 18mmHg; PP 34mmHg; on ausculation of lung fields- decreased breath sounds on the Right IAA and ISA when compared to Left lung fields. 1 Unit of SDP transfusion was done on day 4, 1:30 AM i/v/o petechiae and heavy menstrual bleeding. USG Abdomen was done which showed Gall bladder wall edema, Grade I fatty liver, Minimal Ascites at pelvic and perihepatic space. Hess test was negative, No postural drop. She was started on Oral Tranexamic acid + Mefenamic acid.
*PROVISIONAL DIAGNOSIS :
• DENGUE WITH THROMBOCYTOPENIA AND LEUCOPENIA
*TREATMENT :
✓ Plenty of oral fluids
✓IVF ( NORMAL SALINE , RINGER LACTATE
75 ml / hr )
✓ Inj Xone 1gm IV /BD
✓Inj Mifenac MR PO / BD
✓Tablet okacet 10 mg/PO/BD
✓Tablet Doxy 100mg/PO/BD
✓Tablet metaspas PO / BD
✓Inj Neomol IV /SOS
✓ Tablet PCM 600 mg PO / TID
