25 year old female with fever and thrombocytopenia

 This is an online E logbook 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 an available global online community of experts 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 the comment box are welcome.

 

I’ve 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 history, clinical findings, investigations, and come up with diagnosis and treatment plan.

Following is the view of my case :

Date of admission : 3-9-2022   

Chief complaints :

A 25-year-old female patient came to the casualty with the cheif complaints of fever associated with headache since 5 days.

Loose stools since 2 days

History of present illness : patient was apparently asymtomatic 5 days back ,she went to her village on friday and got bitten by mosquitoes. Then she developed

H/o Fever-

Onset - insidious

Duration- since 5 days

Type - intermittant ,high grade  

It was relieving on taking medications .

 Associated with chills and rigors.

Associated with generalised body aches and weakness

Diurnal variation absent

No increased temperature at night

H/0 loose stools-

Onset - sudden

Duration- 2 days

No.of episodes -5-8 episodes per day

Consistency- semi solid

Volume - small

Colour - black

Non foul smelling

H/0 pain in the epigastric region 

Aggravated on movements

Yesterday morning, she went to a local lab at nalgonda and got her reports done which showed,

At 12:00 pm

1. Low platelet count- 72,000 lakhs 

Later she went to local hospital at nalgonda

At 2:00 pm

1.Low platelet count- 52,000 lakhs 

At 7:30 pm

1.Low platelet count- 35,000 lakhs 

At 8:00 am today

1.Low platelet count- 22,000 lakhs

...later her mother adviced her 

 So she came to our hospital as her mother works at kims hostel.

Daily routine- wakes up at 7:00 am

            Breakfast at 9:00 am outside

           Goes to work -she works as dialysis worker

           Lunch at 12:00 pm

           Returns from work at 8:00 pm

           Takes rest, cooks, does dishes and other works

           Sleeps at 9:00 pm

History of past illness :

Not a known case of, 

Hypertension, diabetes, epilepsy, CAD, asthma, thyroid.

Personal history :

Diet - mixed

Appetite - normal

sleep - adequate

Bowel and Bladder movements -passing black coloured stools

Addictions - no

No known allergies

Drug history : 

No significant drug history

Family history :

No significant family history

General examination :

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

at the time of examination

SHe is examined in a well lit room, with consent taken.

SHe is moderately built and well nourished.

Pallor - absent

Icterus - absent

Cyanosis - absent 

Clubbing - absent

lymphadenopathy - absent

Pedal edema - absent

Vitals : on the day of admission (3/9/2022)

Temperature - afebrile

Pulse rate - 82 bpm

Respiratory rate - 16 cpm

Blood pressure - 110/90 mmHg

SpO2 - 99.6% on Room air

GRBS - 102 mg/dl

Postural hypotension not present:

- Supine BP - 100/70mmHg & On Standing 100/70mmHg

Systemic examination :

CVS : S1 and S2 heart sounds heard

      NO murmurs and thrills

RESPIRATORY SYSTEM : Bilateral air entry present                            position of trachea - centrall

                        Vesicular breathsounds heard

CNS : intact

ABDOMEN :

Soft 

 On deep palpation - tenderness in epigastric region

              No palpable masses

              Bowel sounds heard 

  

     NO organomegaly

Investigations :

On day 1 (3-9-22)

Fever charting

On day 4 (6-9-22)

SDP transfusion has been done on 3-9-22 at 11:25 pm

On day 2 (4-9-22)

On day 3 (5-9-22)

On day 4( 6-9-22)

On day 5 (7-9-22)

Diagnosis- Dengue with thrombocytopenia

Treatment-

On day 1 (3-9-22)

1. IVF NS, RL@100ml / hr

2. INJ PAN 40 mg IV/OD

3. INJ. ZOFER 4mg IV/OD

4. TAB. DOXYCYCLINE 100 mg PO /BD

5.TAB. DOLO 650mg PO/SOS

6.TAB. OROFER- XT PO/ OD

7. INJ. OPTINEURON 1 AMP in 100 ml NS/ STAT

8.BP,PR,SpO2,GRBS, monitoring 4TH HOURLY

On day 2 (4-9-22)

1. IVF NS, RL@100ml / hr

2. INJ PAN 40 mg IV/OD

3. INJ. ZOFER 4mg IV/SOS

4. TAB. DOXYCYCLINE 100 mg PO /BD

5.TAB. DOLO 650mg PO/SOS

6.TAB. OROFER- XT PO/ OD

7. INJ. OPTINEURON 1 AMP in 100 ml NS/ STAT

8.BP,PR,SpO2,GRBS, monitoring 4TH HOURLY

On day 3 (5-9-22)

1. IVF NS, RL@100ml / hr
2. INJ PAN 40 mg IV/OD
3. INJ. ZOFER 4mg IV/SOS
4. TAB. DOXYCYCLINE 100 mg PO /BD
5. INJ. OPTINEURON 1 AMP in 100 ml NS/ IV/OD
6.TAB. OROFER-XT PO/OD
7.TAB.  DOLO 650mg PO SOS
8. Strict I/O charting
9.BP,PR,SpO2,GRBS,Temperature chart ing monitoring 4TH HOURLY

On day 4 (6-9-22)

1. IVF NS, RL@100ml / hr
2. INJ PAN 40 mg IV/OD
3. INJ. ZOFER 4mg IV/SOS
4. TAB. DOXYCYCLINE 100 mg PO /BD
5. INJ. OPTINEURON 1 AMP in 100 ml NS/ IV/OD
6.TAB. OROFER-XT PO/OD
7.TAB.  DOLO 650mg PO SOS
8. Strict I/O charting
9.BP,PR,SpO2,GRBS,Temperature chart ing monitoring 4TH HOURLY

On day 5 ( 7-9-22)

Tab.doxy 100 mg po/od
Tab.pcm 650 mg po sos
Tab.pan 40 mg po od
Tab.orofer xt po od
Tab.zofer po/sos
Plenty of oral fluids 

Discharge summary

Date of discharge:

Date: 7-9-22

Ward: WARD 10

Unit:6

Treating faculty:

Diagnosis;

fever with thrombocytopenia

case history and clinical findings:

Chief complaints :

A 25-year-old female patient came to the casualty with the cheif complaints of fever associated with headache since 5 days.

Loose stools since 2 days

History of present illness : patient was apparently asymtomatic 5 days back ,she went to her village on friday and got bitten by mosquitoes. Then she developed

 

H/o Fever-

Onset - insidious

Duration- since 5 days

Type - intermittant ,high grade  

It was relieving on taking medications .

 Associated with chills and rigors.

Associated with generalised body aches and weakness

Diurnal variation absent

No increased temperature at night

 

H/0 loose stools-

Onset - sudden

Duration- 2 days

No.of episodes -5-8 episodes per day

Consistency- semi solid

Volume - small

Colour - black

Non foul smelling

 

H/0 pain in the epigastric region 

Aggravated on movements

 

PAST HISTORY -

 

Not a known case of, 

Hypertension, diabetes, epilepsy, CAD, asthma, thyroid.

 

PERSONAL HISTORY-

 

 

Diet - mixed

Appetite - normal

sleep - adequate

Bowel and Bladder movements -passing black coloured stools

Addictions - no

No known allergies

 

GENERAL EXAMINATION

 

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

at the time of examination

SHe is examined in a well lit room, with consent taken.

SHe is moderately built and well nourished.

Pallor - absent

Icterus - absent

Cyanosis - absent 

Clubbing - absent

lymphadenopathy - absent

Pedal edema - absent

 

SYSTEMIC EXAMINATION-

 

CVS : S1 and S2 heart sounds heard

      NO murmurs and thrills

RESPIRATORY SYSTEM : Bilateral air entry present                            position of trachea - centrall

                        Vesicular breathsounds heard

 

CNS : intact

ABDOMEN :

Soft 

 On deep palpation - tenderness in epigastric region

 

              No palpable masses

              Bowel sounds heard 

              NO organomegaly

 

 

Treatment given:

1. IVF NS, RL@100ml / hr

2. INJ PAN 40 mg IV/OD

3. INJ. ZOFER 4mg IV/OD

4. TAB. DOXYCYCLINE 100 mg PO /BD

5.TAB. DOLO 650mg PO/SOS

6.TAB. OROFER- XT PO/ OD

7. INJ. OPTINEURON 1 AMP in 100 ml NS/ STAT

8.BP,PR,SpO2,GRBS, monitoring 4TH HOURLY

 

Advice at discharge:

1. PLENTY OF ORAL FLUIDS

2.TAB. PCM 650mg  PO SOS

3. TAB PAN 40mg PO OD

4. OROFER-XT PO OD

Follow up:

review sos

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER

SIGNATURE OF PG/INTERNEE

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY

Investigations

Name  Value  Range  Name  Value  Range  COMPLETE URINE EXAMINATION (CUE)   03-09-2022 04:06:PM  COLOUR Pale yellow  APPEARANCE Clear  REACTION Acidic  SP.GRAVITY 1.010  ALBUMIN +  SUGAR Nil  BILE SALTS Nil  BILE PIGMENTS Nil  PUS CELLS 2-4  EPITHELIAL CELLS 2-3  RED BLOOD CELLS Nil  CRYSTALS Nil  CASTS Nil  AMORPHOUS DEPOSITS Absent  OTHERS Nil  LIVER FUNCTION TEST (LFT)   03-09-2022 04:06:PM  Total Bilurubin 0.56 mg/dl 1-0 mg/dl  Direct Bilurubin 0.18 mg/dl 0.2-0.0 mg/dl  SGOT(AST) 304 IU/L 31-0 IU/L  SGPT(ALT) 167 IU/L 34-0 IU/L  ALKALINE PHOSPHATE 94 IU/L 98-42 IU/L  TOTAL PROTEINS 5.8 gm/dl 8.3-6.4 gm/dl  ALBUMIN 3.45 gm/dl 5.2-3.5 gm/dl  A/G RATIO 1.47 BLOOD UREA   03-09-2022 04:06:PM 18 mg/dl 42-12 mg/dl SERUM CREATININE   03-09-2022 04:06:PM 0.6 mg/dl 1.1-0.6 mg/dl  SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM   03-09-2022 04:06:PM  SODIUM 134 mEq/L 145-136 mEq/L  POTASSIUM 3.9 mEq/L 5.1-3.5 mEq/L  CHLORIDE 103 mEq/L 98-107 mEq/L  CALCIUM IONIZED 0.95 mmol/L mmol/L