A 26 year old with fever and vomotings

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 female patient aged 26 years who is a resident of Nalgonda came with the chief complaints of

              H/o fever and vomitings 
     since 4 days
History of present illness:
           Patient was apparently asymptomatic 20days back and had complaints of dysmenorrhea and oligomenorrhea for which she went for gynecologist and managed conservatively for renal calculi for 7days. 
10days back she again had lower abdominal pain went to nearby hospital ,usg showed pelvic hematoma with mild Hemoperitoneum for which laproscopic salpingectomy was done on 4-11-22 . 2 days after surgery patient developed (Dengue NS1 antigen +ve) and blood transfusions was 

Past history:
           No h/o bleeding manifestations
      No h/o asthma, thyroid disorders, epilepsy, hypertension, diabetes, CAD

Surgical history:
           H/o previous 2 lscs 
And one hysterectomy was done 3yrs ago. 

Family history:
            Not significant

Personal history:
          Appetite:normal

Diet : mixed

Sleep: Adequate

Bowel and bladder movements : regular

Addictions : none

She has no known allergies. 


GENERAL EXAMINATION:

           Patient is conscious , coherent , cooperative and well oriented to date , time and place

Patient is well built and well nourished

VITALS

BP: 120/70 mm hg

PR: 70 bpm

RR: 20cpm

temperature: 98.6*F 

SPO2: 95%

GRBS: 106mg/dl.

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 with

AP diameter : transverse diameter =5:7

Symmetrical expansion of chest

Vocal fremitus is felt. 

PERCUSSION:

Resonant on percussion

AUSCULTATION:

Breath sounds are normal

PER ABDOMEN

Shape : schapoid

Umbilicus: inverted

No visible scars sinuses

No engorged veins

Tenderness : Present

No palpable mass

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:


DIAGNOSIS:

    DENGUE WITH THROMBOCYTOPENIA

S/P: LEFT LAPROSCOPIC SALPHINGECTOMY.

TREATMENT:

1.IVF[1 NS,1RL@100 ML/HR]

2.INJ NEOMOL; 1 GM/IV/SOS[IF TEMP >101F]

3.TAB DOLO 650 MG QID

4.TAB PANTOP 40 MG PO/OD




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