50 year old male patient with fever and SOB
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
50 year male Farmer by occupation came with chief complaints of
Fever since 10 days,
SYSTEMIC EXAMINATION -
Lethargy since 4 days ,
Blood in saliva since 3 days and
SOB since 2 days
Patient was apparently alright 10 days back then he had low grade fever , intermittent , relieved on taking medication . Not associated with chills and rigors and was able to perform his routine works. From 4 days as patient was lethargic and taken to local hospital found out to be Dengue NS 1 + and platelet count was
44,000 on day 1
22,000 on 2nd day
Following one SDP transfusion, it became
33,000 on 3rd day
From 3 days patient notices blood in saliva during coughing and Black coloured stools from 2 days , patients SOB progressed from Grade 2 --- Grade 4 ( MMRC ).
PAST HISTORY :
Not known case of Diabetes, Hypertension , Asthma , TB , Epilepsy .
PERSONAL HISTORY :
Diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movements- regular
Addiction : alcohol intake daily 30 ml whisky
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
No Pallor , icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema
SYSTEMIC EXAMINATION:
CVS: S1,S2 heard, no murmurs heard
RS: Bilateral air entry present, ronchi are heard
P/A: Soft, Non-tender
CNS: No abnormalities seen
PROVISIONAL DIAGNOSIS :
SEVERE ARDS with Dengue NS 1 reactive with Thrombocytopenia . ( H/O 1 SDP and 1 FFP transfusion )
TREATMENT :
1. IVF NS , RL @ 75 ml/hr
2. Daily postural BP monitoring
3. W/F Bleeding manifestation
4. I/O strict monitoring
S.O.A.P notes
5/3/22
S :
Fever and SOB
O :
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA
VITALS -
TEMPERATURE - 98.1
PULSE RATE - 60 bpm
BLOOD PRESSURE - 110/70 MM OF HG
RESPIRATORY RATE -
SPO2 - 100 % AT 4 lit O2
I - 1900 ml
O - 500 ml
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT, RONCHI HEARD
CENTRAL NERVOUS SYSTEM : NAD
A :
ARDS with Dengue NS 1 reactive with Thrombocytopenia . ( H/O 1 SDP and 1 FFP transfusion )
P :
1. IVF NS , RL @ 50 ml/hr
2. W/F Bleeding manifestation
3. Strict I/O charting
4. BP monitoring
6/3/22
S :
Fever and SOB
O :
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA
VITALS -
TEMPERATURE - 98.1
PULSE RATE - 60 bpm
BLOOD PRESSURE - 110/70 MM HG
RESPIRATORY RATE - 35 cpm
SPO2 - 100 % AT 4 lit O2
I - 2000 ml
O - 1050 ml
HB - 10.8 4/3/22
10.1 5/3/22
9.8 6/3/22
Pt - 17000 4/3/22
18000 5/3/22
52000 6/3/22
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM :
B/LAE+,inspiratory crepts present in (RT>LT) infraaxillry , infrascapular areas
CENTRAL NERVOUS SYSTEM : NAD
7/3/22
S :
Fever ( subsided ) and SOB
O :
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA
VITALS -
TEMPERATURE - 98.4
PULSE RATE - 60 bpm
BLOOD PRESSURE - 120/70 MM HG
RESPIRATORY RATE - 20 cpm
SPO2 - 98 % AT 2 lit O2
HB - 10.8 4/3/22
10.1 5/3/22
9.8 6/3/22
10.1 7/3/22
Pt - 17000 4/3/22
18000 5/3/22
52000 6/3/22
50000 7/3/22
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM :
B/LAE+,inspiratory crept’s present in (RT>LT) infraaxillry , infrascapular areas
CENTRAL NERVOUS SYSTEM : NAD
A :
Dengue NS 1 reactive , IgM positive with Thrombocytopenia, with Mild ARDS
P:
1. IVF NS , RL @ 50 ml/hr
2. W/F Bleeding manifestation
3. Strict I/O charting
4. BP monitoring
Comments
Post a Comment