21yr 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT

Case

21 year old female patient from Ismail palli, who is  a Bsc nursing student ,came to the casuality with chief complaints of  
•Fever since  21/7/22
•Body pains
•Vomitings since 21/7/22 evening
•non-productive cough

HOPI :
The patient  presented  with fever which is insidious in onset,high grade,continous,associated with chills&body pain since 10 am 21/7/22

H/o Vomitings on 21/7/22 evening 6 episodes , non bilious type,non-projectile, food particles and water as content,was associated with abdominal pain(h/o Outside food intake - corn,chicken on 20/7/22)

No H/o loose stools

No H/o burning micturation,shortness of breath,chest pain,palpitations,diarrhoea.

Daily routine :
 Wakes up at 7 am,do her regular activities,have breakfast and attend college classes,clinicals,have lunch at 1pm and attend college from 2-4pm , and having snacks on road side frequently, goes to bed at 10pm

Past history : 
Not a known case of diabetes/ hypertension/asthma/CAD/CVA/Epilepsy/Typhoid/Thyroid disorders
No previous surgical history.

Personal history :
•Diet : mixed
•Appetite :  decreased since the fever
•Sleep :  distributed sleep because of chills and rigor
•Bowel  movements :
 Vomitings 
•Bladder movements: Regular
•Addictions : None
 
Allergies :
 Allergic to potato , Roselle leaves and brinjal

Family history : not significant

Menstrual history : 
 Age of menarche : 12
 Duration of mensuration : 5 days
 LMP : 25/6/22
 Regular : 5/30
 No other Gynecologic problems

Immunization status : 
Vaccinated up to date
 Vaccinated for covid -19

      GENERAL EXAMINATION  •Patient is examined in a well lit room after obtaining consent
•Patient is conscious, coherent, cooperative.
 Well built and well nourished. 
 •Height -5'2
 • Weight - 55 kgs
•Pallor , Icterus,clubbing, cyanosis, koilonychia, edema are absent

VITALS :

Temp- 100f
Bp-100/80 mm hg
PR- 84bpm
RR-16CPM
Spo2- 99% on RA
GRBS : 102



              SYSTEMIC EXAMINATION 


RS-.   bilateral air entry present 
CVS :    S1, S2 + no murmurs 
P/A-    soft and non tender
bowel sounds present 
CNS :.  No focal neurological defeicit 
HMF intact 
Power in B/L upper and lower limb Is 5
Reflexes are present with B/L plantars and flexors

INVESTIGATIONS : 
                                On 22/7/22
                     
*HEMOGRAM

*RFT 



*COMPLETE URINE EXAMINATION :



*APTT



*BLEEDING AND CLOTTING TIME


*BLOOD FOR M.P.-STRIP TEST



*PROTHROMBIN TIME 



*BLOOD GROUPING AND Rh TYPING 

On 23/7
On 24/7/22"

*Haemogram
6 : 30 am
10 : 30 pm
*Malarial parasite

"On 25/7/22"
*Hemogram

(9 am)


(7pm)

*Record of Temparature,BP, RR AND SPO2

                         *USG Abdomen


On 26/7/22"

                          *Haemogram


                           *Blood Urea



                      *Serum Creatinine


 *Serum electrolytes & Serum Iodized Calcium

                      

                             "On 27/7/22"

                              *Haemogram
 
            Fever chart
        
             Xray

PROVISIONAL DIAGNOSIS : 

 • DENGUE WITH THROMBOCYTOPENIA AND LEUCOPENIA


*TREATMENT : :Plenty of  oral fluids 

IVF ( NORMAL SALINE , RINGER LACTATE )

75 ml / hr 

 Inj Xone 1gm IV /BD

Inj Mifenac  MR PO / BD

Tablet okacet PO/BD 

Tablet Doxy 100mg/PO/BD 

Tablet metaspas PO / BD

Inj Neomol IV /SOS

Tablet PCM 600mg PO/TID

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