MEDICINE CASE DISCUSSION

9th june ,2021

case of 48years female patient with dengue

ROHITH SOMANI

MBBS 8th semester 

roll no:127

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 and treatment plan.

CASE DISCUSSION

A 48 yrs old female patient presented with chief complaints;

• fever since 5 days
• vomiting and pain abdomen since 3 days

history of present illness:

• patient was apparently asymptomatic 5days back she had high grade fever which was intermittent and not associated with chills and rigors
•  3days back and developed per abdominal pain and vomiting 
• pain type: colicky type
• and she had an 2-3 episodes of vomiting per day which was non-projectile and non-bile stained
• generalized weakness and decrease appetite since 3 days

went to local hospital and was diagnosed dengue positive and was referred to our hospital as her platelet count was low

history of past illness:

no H/O cough ,cold, SOB

no H/O loose stools, bleeding gums

no H/O any rash over body

no other complaints

not a k/c/o: DM, HTN, Asthma, epilepsy, CAD, TB

treatment history: 

no previous treatment history

personal history:

appetite-decreased since 3days

bowl and bladder movements- normal

no allergies

no addictions

familial history:

not significant

physical examination:

Patient was examined in a well lit room, after taking informed consent.

conscious, coherent, cooperative, well-nourished, well -oriented to time, place, person

 Pallor: no

     Icterus: no

     Cyanosis: no

     Lymphadenopathy: no

    Edema: no 

    Clubbing of fingers: no

vitals:

    temperature:100degrees F 

    RR:18/min

    PR:86/min

    BP:130/80mm Hg

    Spo2:98%

systemic examination:

 CVS: S1 & S2 heard 

           no murmurs and cardiac thrills

RESPIRATORT SYSTEM:

no dyspnoea

no wheeze

position of trachea is central

breath sounds-vesicular

ABDOMEN:

 Inspection

  the shape of the abdomen: scaphoid

 palpation;

   Tenderness- present in right hypochondrium, epigastrium, umbilical

    no palpable mass

   hernial orifices: normal

   liver and spleen not palpable

percussion :

liver span: normal

auscultation;

  bowel sounds: yes 

CNS: intact

gait-normal

investigations

USG abdomen:

gallbladder wall edema

mild ascites

right kidney mild hydronephrosis

chest x-ray

hematology report

WBC : lymphocytic leucocytosis

platelet : thrombocytopenia 

                

 

blood group: AB+ve

bilirubin level: 

total bilirubin: elevated

 direct bilirubin: elevated

 

blood urea:

serum electrolytes:

probable diagnosis: 

dengue as the test for NS1 antigen is positive.

treatment:

• i.v fluids: normal saline or ringer lactate at rate of 150ml/hr
• TAB.PAN 40MG OD in morning before breakfast
• INJ. OPTINUERON 1ampule in 100ml NS IV/OD
• TAB.DOLO 650MG BD
• BP/PR/TEMP/SPO2 monitoring every 4hours
• W/F bleeding manifestation