57yr old female came with complaints of fever, vomitings,

 This is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 patient's clinical problems with collective current best evidence-based inputs .

CASE SCENARIO:

60yr old female came with chief  complaint of vomitings since 5 days 1 epsode per day, fever since 3 days , cough present on and off,chest pain ( on and off)since 3 days, shortness of breathe since 1 day

HISTORY OF PRESENTING ILLNESS:

Patient was apparently normal 5 days ago, Then she developed fever with chills and rigors, Nausea and vomitings 1 episode per day ( Non projectile, Non bilious, Content is of food £particles).

 Abdominal pain  of pricking type with no aggravating or relieving factors.  Then she had  2-3 episodes of watery stools per day.She then developed chest pain since 3 days along with back pain  she is having shortness of breathe from yesterday , also  Cough with sputum and whole body weakness.

E 33

HISTORY OF PAST ILLNESS:

k/c/o HTN since 1yr ( on medication not known)

Wedded dTREATMENT HISTORY:

Tsotal abdominal hysterectomy  done.

PERSONAL HISTORY:

Married 

Occupation: daily wage labour

Diet: Mixed , Non vegetarian 

Appetite: decreased since 5 days 

Bowels: watery stools 

Micturation : decreased 

Known Allergies: No

Addictions: alcohol occasionally. 

FAMILY HISTORY:

No significant history. 

General Examination. 

No Pallor  icterus , cyanosis, clubbing , lymphadenopathy, pedal edema 

VITALS :

Temperature - 96.9 °F

Pulse - 90 beats/min

BP - 120/80 mmHg

RR - cycles/min

GRBS - mg%

SPO2 - 100 %

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No

RESPIRATORY SYSTEM

Dyspnoea:No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Adventitious sounds : No

ABDOMEN

Shape - Scaphoid 

No tenderness, palpable mass, No Fluid 

No bruits

Liver not palpable 

Spleen not palpable. 

Bowel sounds present.

CNS Examination:

Conscious coherent cooperative. 

Speech normal.

No signs of meningitis 

Cranial nerves, motor system, sensory system Normal. 

PROVISIONAL DIAGNOSIS:

DENGUE with NS1 positive  and THROMBOCYTOPENIA.

Investigations:

TREATMENT :

IV fluids NS     RL @ 100ml/hr

Inj Optineuron 1amp in 100 ml IV/OD

Inj Pan 40 mg IV/OD

Inj Zofer 4 mg IV /SOS

TAB Dolo 650 mg TID

Inj Doxy 100 mg IV/BD

Inj Neomol 1mg IV/SOS

 Strict I/O Charting

W/F Bleeding manifestation

 Monitor vitals and inform SOS