GENERAL MEDICINE E-LOG

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

CHIEF COMPLAINT:

A 24 year old female came to the opd with chief complaints of 

  • Fever 
  • Vomitings and
  • Bloating since 3 days 
HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 3 days back, then she developed fever associated with chills and rigor( subsided on taking medication). Fever was present throughout the day which was of Intermittent type with no diurnal variation.

She had complaints of bloating followed by vomitings ( 3 episodes in a day) which had food particles as content.

No bleeding manifestation

No c/o burning micturition 

No c/o cough, cold, headache, pedal edema

Patient was taken to the near by RMP doctor was told her platelet count was low and was referred to our hospital.

HISTORY OF PAST ILLNESS:

Not a k/c/o DM, Hypertension, Asthma, TB, epilepsy.

No similar complaints in the past.

TREATMENT HISTORY:

NO relevant treatment history

PERSONAL HISTORY:

  • Married for 3 years
  • Appetite is normal and improved
  • Having mixed diet( Non vegetarian)
  • Bowels- Regular
  • Micturition- Normal 
  • No other habits/addictions
GENERAL EXAMINATION:

Patient is conscious.

Pallor is present.

Absence of Icterus, Clubbing, Cyanosis, Pedal edema, Lymphadenopathy.

VITALS:

1.Temperature: 98.6 F

2.Pulse rate: 84 beats per min

3.Respiratory rate: 18 cycles per min 

4.BP: 100/80 mm Hg

5.SpO2: 99% @ Room air 

6.GRBS: 106mg% 

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

  • S1, S2 heard
  • No thrills, No murmurs
RESPIRATORY SYSTEM:

  • Normal vesicular breath sounds
  • Position of trachea is central
  • Dyspnoea is absent
  • No wheeze
EXAMINATION OF ABDOMEN:

  • Shape- scaphoid
  • Tenderness is present in right hypochondriac region
  • No palpable pass
  • Normal hernial orifices 
  • No free fluid
  • No Bruits
  • Liver is not palpable
  • spleen is not palpable
  • Bowel sounds heard
CENTRAL NERVOUS SYSTEM:

  • Patient is conscious 
  • Speech is normal 
  • No focal neurological defect
PROVISIONAL DIAGNOSIS:

VIRAL PYREXIA WITH THROMBOCYTOPENIA 

INVESTIGATIONS:

Investigations on 13/08/21:

                                 

                                                                      chest X-Ray 

   

ECG


DENGUE NS1 Antigen, IgG and IgM( Rapid test) 


Hemogram 


Blood Parasites(M.P.)


Ultrasound report

Investigations on 14/08/21:

Haemoglobin: 11.2gm/dl

Platelet count: 80,000/cells/cumm

TLC : 8,110cells/cumm 

TREATMENT:

Treatment on Day 1:

1. IVF  20NS 100ml/hr
           20RL 100ml/hr
2. Inj. PAN 40mg IV/OD
3. Inj. ZOFER 4mg IV/STAT
4. Inj. OPTINEURON 1 ampule
                1hr 100ml NS/IU/OD
5. BP/PR/RR/SpO2 CHARTING 4th hrly
6. STRICT I/O CHARTING

Treatment on Day 2:

1. Plenty of oral fluids
2. Inj. 10NS 75ml/hr 
          10RL 75ml/hr
3. Tab Pantop 40mg/PO/OD
4. Tab MVT/PO/OD
5. Strict I/O Charting 
6. BP/PR/SpO2 Charting 4th hrly
7. GRBS Charting 2th hrly 





 






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