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




Popular posts from this blog

MEDICINE BLENDEDMONTHLY ASSESSMENT

Image
I have been given the following cases to solve in an attempt to understand the topic of 'Patients clinical data analysis' to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations anddiagnosis and come up with treatment plan . This is the link of the questions asked regarding the cases: http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1 Below are my answers to Medicine assignment based on comprehension of the cases. Case:1 https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html Questions 1. what is the evolution of the symptomatology in this patient interms of an event timeline and where is the anatomical localisation for the problem and what is the primary etiology of the patient  problem ? 1Ans)Evolution of symptomatology 1st episode of sob - 20 yr back 2nd episode of sob - 12 yr back From then she has been having yearly episodes fo
Read more

COVID e Logs

Image
1) Covid 19 with co morbidity (Pulmonology/Rheumatology)   https://nikhilasampathkumar.blogspot.com/2021/05/covid-pneumonia-in-pre-existing-case-of.html Questions:  1) How does the pre-existing ILD determine the prognosis of this patient? Ans. The pre-existing ILD significantly worsens the prognosis of this covid patient.  Interstitial lung disease is characterized by dyspnea, decreased pulmonary diffusing capacity, decreased FVC and TLC. The SpO2 of these patients is usually decreased due to increased A-a gradient A superimposed covid-19 infection in these cases can cause an acute exacerbation of symptoms such as dyspnea, decreasing levels of SpO2 further and faster than in Covid-19 patients without interstitial lung disease.  Radiology (HRCT) usually shows the development of new pulmonary opacities and fibrosis. Patient factors:  Since this patient already had a reduced SpO2 of 90-92% (compared to the normal range of >96%) she is more susceptible to worsening of hypoxi
Read more

A 61 year old female with hypoglycemia

Image
This is an online e-log platform to discuss case scenario of a patient with their guardians permission.  I have 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 histoty, clinical findings, investigations and come up with a diagnosis and treatment plan.. CASE: A 61 year old female who is resident of narketpally, came to OPD on 21st november at 12am with. Chief complaints of:  - stiffness of muscles of hands and neck  - slurred speech - deviation of mouth towards right. History of present illness: Patient was apparently asymptomatic 10yrs back and then she developed faintness, numbness and tingling sensation, burning sensation of hands and foot espcially during night and was diagnosed with Diabetes Mellitus for which she is on medication. 8months back she developed neck pain, headache, leg pain, body pains and was diagnosed with Hypertension for which she is
Read more