45 yr old lady with dengue- thrombocytopenia
August 21, 2022
Hi, I am Shaik Ayesha , 3rd Sem Medical Student.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 individual 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 on the 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 a diagnosis and treatment plan.
CHIEF COMPLAINTS :
Patient was suffering with fever, chills, headache and generalised body pains since 10 days and short of breathe since 5 days and the fever was intermittent when she was on medication and weakness since 10 days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 10 days back then she developed fever along with chills which was intermittent in nature and relieved on medication and also she had headache and generalised body pain.since 5 days patient had shortness of breathe on exertion which os gradually progressed now to grade 2 or 3. She had abdominal pain while doing work.
PAST HISTORY:
Last year she had uterine swelling and was on mediciation for few months which is now completely alright
She had no similar symptoms in past
No complaints of chest pain,palpitation and syncobal attacks
No pedal edema
No burning miturition
No decreased urine output
NO SIGNS OF ANY BLEEDING MANIFESTATIONS
No hypertenion
No DM
No TB
No asthma
No CAD
No surgeries in past
No chemotherapy in past
No blood transfusion
PERSONAL HISTORY
Married
Occupation: farmer
Lost appetite
Mixed diet
Regular bowel movement
No history of allergies
Non alcoholic
FAMILY HISTORY
no DM
No hypertension
No heart disease
No cancers
No TB
No stroke
No asthma
GENERAL EXAMINATION
conscious
Coherent
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No edema of feet
No malnutrition
No dehydration
VITALS
BP 110/70 mmhg
HR 99 bpm
temperature 98'F
Respiration 34
SpO2 96
Random blood sugar 122
SYTEMIC EXAMINATION
CVS
No thrills
S1 S2 present
No cardiac murmers
RESPIRATORY
Shortness of breathe
No wheezing
Centrally placed trachea
ABDOMEN
scaphoid shape
No tenderness
No palpable mass
Normal hernial orifices
CNS
conscious
Normal speech
No neck stiffness
No kerning sign
Cranial nerves normal
Motor system normal
Sensory system normal
Glassgow scale normal
INVESTIGATIONS
dengue- thrombocytopenia
Polyserositis
MEDICATION
Dolo 650mg
Neomol 150 IV
Doxy 100mg
Flacigo 120 mg IV
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