22 Year old female with dengue

23/10/2022
Student Name- D.Vineesha Chowdary 
2017 batch


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 evidence based input
This E blog 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 diagnosis and treatment plan. 

CHIEF COMPLAINTS-
 A 22 year old female presented to the OPD with chief complaints of-- Fever with chills since 5 days - Generalised weakness since 5 days - Headache since 5 days - Body pains since 5 days - Nausea since 5 days 

HISTORY OF PRESENTING ILLNESS-

Patient was apparently asymptomatic 5 days ago when she developed fever associated with chills. She also had generalised weakness, headache and body pains associated with the fever. 

PAST HISTORY- 

Patient is not a known case of hypertension, diabetes, TB, asthma or epilepsy.
FAMILY HISTORY-

The patient’s mother and father have similar complaints since a week and have been diagnosed with dengue fever. 
PERSONAL HISTORY-Appetite- reduced Diet- MixedBowel movements- normal Bladder movements- normal Sleep- adequate Any addictions- No Any allergies- No 
GENERAL EXAMINATION-

Done after obtaining consent, in the presence of attendant with adequate exposure
Patient is conscious, coherent, cooperative and well oriented to time, place and person
Patient is well nourished and moderately built

Vitals-

On 15/11/22
Temperature- 99.8F
Blood pressure- 100/80 mmHg
Pulse rate- 82 bp
Respiratory rate- 20cpm
SpO2- 99%

Pallor- present 
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Edema- Absent

On 16/11/22

Temperature- 99F
Blood pressure- 100/60 mmHg
Pulse rate- 80 bp
Respiratory rate- 20cpm
SpO2- 99%

Pallor- present 
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Edema- Absent

ABDOMINAL EXAMINATION-

INSPECTION- Umbilicus inverted , No abdominal distention, no visible pulsations, scars and swelling.

PALPATION-  Soft, non tender, no organomegaly.

AUSCULTATION- Bowel sounds heard

CVS EXAMINATION-

INSPECTION- No visible pulsations, scars, engorged veins. No rise in JVP. 

PALPATION- Apex beat is felt at 5th Intercoastal space medial to mid clavicular line.

AUSCULTATION- S1, S2 heard, no murmurs.

RESPIRATORY SYSTEM-

INSPECTION-  Shape of chest is elliptical, b/l symmetrical.

PALPATION- Trachea is central. Expansion of chest is symmetrical.

  Bilateral Airway Entry - positive

AUSCULTATION- Normal vesicular breath sounds.

CNS EXAMINATION-

No signs of meningeal signs

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

Gait: normal.


INVESTIGATIONS- 


HAEMOGRAM- 


CUE-


S.ELECTROLYTES- 


S.UREA-


S.CREATININE-


S.IRON-


DENGUE RAPID TEST-


LFT-

ECG-

2D ECHO-



CHEST X RAY- 



PROVISIONAL DIAGNOSIS- 


DENGUE FEVER 


TREATMENT- 


1) IVF NS/RL @100ml/hr

2) INJ.PANTOP 40mg/IV/OD

3) INJ.ZOFER 4mg PO/OD 

4) INJ.NEOMOL 100ml IV 

5) T.DOLO 650mg PO/TID

6) FEVER CHARTING 4th hourly 




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