50 year old female with fever

 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 patients 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 comment box is welcome. 


A 50 year old female patient agricultural labourer by occupation was bought to the casualty with the chief compliants of fever since 5 days

Loose stool since 1 day( 3 episodes)

Vomitings since 1 day ( 2 episodes)

HOPI.

Patient was apparently asymptomatic 5 days back then she developed fever which was high grade, intermittent in nature  associated with chills and rigors and relieved on medication.patient also had a history of loose stools( 3 episodes) water in consistency . She also had history of 2 episodes of vomiting which is non bilious non projectile with  food as contents.

No H/O bleeding manifestations, pain abdomen , head ache, chest pain,cough.

PAST HISTORY

No similar complaints in the past.

Not a known case of diabetes, Hypertension,asthama, epilepsy tuberculosis,CAD,CVA.

FAMILY HISTORY: Her son had similar history and got admitted yesterday.

PERSONAL HISTORY

DIET: mixed.

APPETITE: NORMAL

SLEEP: adequate

BOWEL AND BLADDER MOVEMENTS: regular

No addictions

No allergies.

ON GENERAL EXAMINATION

patient is conscious, coherent,co operative well oriented to time, place and person,  moderately built and moderately nourished

AFEBRILE

Bp:110/70 mm hg

PR:86bpm

RR;16cpm

Spo2:96% at room air

GRBS:293mg%

Physical Examination: 

       Pallor:absent

       Icterus: absent

cyanosis: absent

clubbing : absent

lymphadenopathy:absent

pedal edema: absent 

SYSTEMIC EXAMINATION:  

CVS

S1 and S2 are heard

No thrills

No murmurs

RESPIRATORY SYSTEM

INSPECTION: 

Tracheal position is central

Symmetrical chest 

PALPATION:

All inspectory findings are confirmed by palpation

Trachea is central

Chest is symmetrical

Symmetrical expansion of chest. 

PERCUSSION:

Resonant on percussion. 

AUSCULTATION:

Breath sounds are normal. 

PER ABDOMEN

Shape : scaphoid

Tenderness : Present

No palpable mass

Hernial orifices : Normal

No free fluid

No bruits

Bowel sounds : present

CNS 

Conscious

Speech : Normal

No signs of meningeal irritation

Cranial nerves : intact

Motor system : Normal

Sensory system : Normal

Reflexes : Normal. 

INVESTIGATIONS:

HEMOGRAM.

HB:12.8

TLC:2000

PCV:39.3

PLT:30,000

SEROLOGY: NEGATIVE.

APTT: 33 sec

BLEEDING TIME: 2 min 30 sec

CLOTTING TIME: 4 min 30 sec

RBS:114

BLOOD UREA:. 38

NS1 : POSITIVE.

TOTAL BILURUBIN:0.69

DIRECT BILIRUBIN:0.18

SGOT;79

ALP:133

SGPT:28

TOTAL PROTIEN:5.5

AlBUMIN:3.3

PROTHROMBIN TIME:16 sec

INR:1.11

SERUM CREATININE:0.9

SODIUM:138

POTASSIUM:4

CHLORIDE:102

STOOL FOR OCCULT BLOOD - POSITIVE

PROVISIONAL DIAGNOSIS

VIRAL PYREXIA (? DENGUE FEVER)

TREATMENT

1.ivf ( 2 NS,1 RL@ 100 ML/HR)

2.INJ NEOMOL 1 GM IV/BD( IF TEMP> 101F)

3.TAB DOLO 650 MG / TID.

TAB ZOFER 4 MG PO/SOS.

5.MONITOR VITALS 2ND HRLY































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