General medicine case 3
21 year old female patient with fever with chills and body pains
September 13, 2022
Hello, I'm B.Arundathi, 3rd semester medical student. This is our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. This elog also reflects my patient centered online learning portfolio.
A 21 yr old female housewife by occupation came with
Chief complaints :
1. Fever since 4 days
2. Vomiting 2- 3 episodes/day since 3 days
3. Body pains since 4 days
HOPI :
Patient was apparently asymptomatic 4 days back then she developed fever, more in the evening associated with chills relieved with medication. Then patient started having vomiting since 3 days 2-3 episodes per day, with food as contents, non-projectile, non-bilious and not stained with blood. Patient had body pains since 3 days which was more in lower back, hands and legs which was not relieved with medication.
No h/o headache
No h/o diarrhea, vomiting.
Past History :
Not a k/c/o DM,htn,tb,asthma,epilepsy
On presentation:
Pt conscious,coherent,cooperative,well oriented to time place and person.
General Examination : No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema
PHYSICAL EXAMINATION
GENERAL EXAMINATION
Well built
Well nourished
No pallor
No icterus
No cyanosis
No clubbing of fingers
No pedal oedema
No lymphadenopathy
VITALS
BP- 110/70mm Hg
PR- 94bpm
RR- 20 cpm
Temp - 98.6
GRBS- 71 mg/dl
INVESTIGATIONS :
1. Hemogram (12-09-22)
2.RBS
4. Serum electrolytes
5. Ultrasound
6. Chest X-ray
7. Hemogram
8. Dengue (NS1) - POSITIVE
9. M. P. Strip test
10.Blood group and Rh type
PROVISIONAL DIAGNOSIS :
DENGUE (NS1 POSITIVE WITH THROMBOCYTOPENIA)
TREATMENT :
1)INJ. NEOMAL 1gm IV if temp > 102°F
2) TAB DOLO 650mg PO/ TID
3) INJ PAN 40mg IV / OD
4) INJ ZOFER 4 mg TID/ SOS
5) IVF 10 RL @ 100 ml/ hr
6) TEMP AND VITALS MONITORING 4th hrly
