44yr old female with fever

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome

Name: K.G. Prasuna Reddy
Roll no. 59

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.



Following is the view of my case :


44YR OLD FEMALE WITH C/O FEVER WITH CHILLS SINCE 4 DAYS ACCOMPANIED BY HEADACHE AND BODY PAINS
PATIENT WAS APPARENTLY ASYMPTOMATIC TILL 4 DAYS BACK, WHEN SHE SUDDENLY HAD BILATERAL LOWER LIMB, PRICKLING PAIN, WHICH RELIEVED AFTER 30 MIN OF TAKING PCM. ONE HR LATER SHE DEVELOPED SUDDEN LOW GRADE FEVER WITH CHILLS AT NIGHT, NOT SUBSIDED WITH MEDICATIONS.
THROBBING HEADACHE LOCALIZED TO B/L TEMPORAL REGIONS, NON RADIATING, ASSOCIATED WITH NAUSEA, WENT TO LOCAL HOSPITAL NEXT MORNING, INVESTIGATIONS DONE AND DIAGNOSED AS DENGUE FEVER , TREATMENT GIVEN, CAME TO OUR HOSPITAL FOR FURTHER TREATMENT 

NOT K/C/O DM, HTN, ASTHMA, TB, CVA, CAD, EPILEPSY 

PERSONAL HISTORY:
APPETITE NORMAL
DIET MIXED
BOWEL AND BLADDER HABBITS REGULAR
SLEEP ADEQUATE 
NO KNOWN ALLERGIES 

NOT SIGNIFICANT FAMILY HISTORY

NO PALOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA

VITALS:
BP: 100/70
PR:88
RR: 18
TEMP: 99F
SPO2: 98% AT RA


INVESTIGATIONS:
HB: 12.7
TLC: 2070
PLT: 30,000
RBC: 4.4
NA: 137
K: 3.9
CL:101
CA: 0.90
CREAT: 0.7
UREA: 21
LFT:
TB: 0.95
DB: 0.20
AST: 29
ALT: 14
TP: 5.8
ALB: 3.0
A:G: 1.09





PROVISIONAL DIAGNOSIS:
VIRAL PYREXIA ( DENGUE) WITH THROMBOCYTOPENIA 


TREATMENT:
17/12/22
INJ PCM 1G IV IF TEMP MORE THAN 101F
IVF AT 100ML PER HR
PLENTY OF ORAL FLUIDS

18/12/22

INJ PCM 1G IV IF TEMP MORE THAN 101F
IVF AT 100ML PER HR
INJ ZOFER 4MG IV SOS
TAB PCM 650MG PO SOS
PLENTY OF ORAL FLUIDS

19/12/22

INJ PCM 1G IV IF TEMP MORE THAN 101F
IVF AT 100ML PER HR
INJ ZOFER 4MG IV SOS
TAB PCM 650MG PO SOS
PLENTY OF ORAL FLUIDS

20/12/22
T zofer 4mg po sos
T pan 40mg po od 
T pcm 650mg po sos
Plenty of oral fluids






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