Monday, January 2, 2023

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.


60 year old female resident of pallipadu presented with chief compliants of:
Fever since 10 days
 Generalised Weakness since 10 days 
Backache since 10 days 
Pedal edema since 2 days

History of presenting Illness:

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

Patient complains of backache since 10 days , continuous which is insidious in onset,pain is confined to shoulder mostly ,dull aching type,non radiating,with no aggravating and relieving factors.

Patient complains of Generalised Weakness since 10 days 
 
Patient went to Rmp doctor ,used medicines for 2 days which didn't subside ,so they went to Nalgonda government hospital and was diagnosed with dengue and low platelet count ,medicines were taken for 3 days which gave no relief 
Patient went to miryalaguda  hospital on 28 December  , got admitted and came to KIMS for further management .


Past History:
Patient has no similar complaints in the past 
No surgeries underwent into the past
No history of Diabetes mellitus, hypertension, coronary artery diesease,asthma, epilepsy, tuberculosis.

Personal History:
Patient takes mixed diet, appetite is decreased, bladder movement is normal, patient complains of decreased bowel movements.
Addictions: Patient consumes alcohol occasionally (1-2pegs).
      Patient smokes chutta since 50 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 oriented to time, place and person. She is well built and well nourished.

Pallor- Present


Icterus- present 

Cyanosis - Absent

Clubbing - Absent

 Generalised Lymphadenopathy- Absent

Bilateral Pedal Edema is present.

Vitals
Temperature: afebrile
BP- 90/70 mmHg
Pulse-81 beats per minute 
RR- 15 cpm

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:

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 fever with Thrombocytopenia with Acute Kidney injury ,Acute Liver injury.


Investigations:



Liver function test
1/1/23


2/1 /23

Serum electrolytes:
1/1/23
2/1/23
Serum creatinine:
1/1/23
2/1/23

 Blood Urea
1/1/23



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 .