147 Viswanath GM, DENGUE


Viswanath Garudadhri 


Roll no -147 , 3rd sem 


 Under the guidance of Dr. Manasa (intern) 


  This is an online e-log platform to discuss case scenarios of a patient with their guardian's 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, history, clinical findings, investigations, and come up with a diagnosis and treatment plan. 


CASE SCENARIO


     A 40 yr old female came to casuality with cheif complaints of weakness and nausea since 1 day.


HISTORY OF PRESENTING ILLNESS


Went to local hospital. Was referred here later.

Decreased platelet count

Fever-4 days ago Low grade, intermittent

vomiting :2-3 episodes 2 days back

Non Bilious, Non projectile No pain abdominal


No other complaints 


HISTORY OF PAST ILLNESS 


    Not a k/c/o DM, Asthma, Epilepsy, TB, HTN


TREATMENT HISTORY 

NIL


PERSONAL HISTORY


 Married

 Occupation?? 

 Normal appetite

 Micturition normal

 No known allergies


FAMILY HISTORY

No data available


GENERAL EXAMINATIONS

    No -pallor/Icterus/Cyanosis/Clubbing/Lymphadenopathy/Edema/Malnutrition

Temperature -98.4 F

Pulse rate - 103 /min

Bp - 100/80 mm/hg

SpO2 - 98%


SYSTEMIC EXAMINATION


CVS:  

No Thrills

Cardiac Sounds - S1, S2 +

No cardiac murmurs


RESPIRATORY SYSTEM: 

Dyspnoea - No

No Wheezing

Position of Trachea - central

Vesicular sounds 


ABDOMEN:

Shape - Obese

No palpable mass, No bruits

Bowel sounds- present

Hernial Orifices - Normal

Liver Spleen - Not palpable

Genitals speculum examination, PV examination, P/R examination - normal


CNS:

Level of consciousness - conscious

Speech - Normal

No signs of meningeal irritation

Cranial nerves - Normal

No motor or sensory deficit

Glassgow scale -15/15


GAIT, MUSCULO SKELETAL SYSTEM, SKIN, EXAMINATION OF BREAST, ENT, TEETH AND ORAL CAVITY, HEAD AND NECK - NORMAL 

Investigations




PROVISIONAL DIAGNOSIS 

Dengue  NS1 positive
Thrombocytopenia present


TREATMENT

IV 200ml/hr 

Tab: Dolo 650 mg Tin

Tab. PAN 40 yong

Inj. OPTINEURON 1 amp in 100ml NS IV / 3D.

Ins. NEOMOL 1gm IV/SOS (IF tep >101F)

W/F Bluding manifestations

Daily platelet Count & pcv monitoring

Regular bp/spo2 monitoring

Inj ZOFER 4mg

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