A 53 yr old female with fever and pain abdomen.
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Prothrombin time- 18sec(Normal :10-16sec)
Blood Urea & Serum Creatinine-
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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 diagnosis and treatment.
Aruna.J
Roll no.61
A 53 yr old female with complaints of:
Fever since 3 days
Generalized body weakness and
Pain Abdomen 4 days.
History of Presenting Illness:
Patient was apparently asymptomatic 4 days back.
Then she developed fever which was continuous in nature associated with chills and rigors, headache, generalized body weakness, and relieved on taking medication.
Pain abdomen was diffuse in nature which is dragging type, non radiating and associated with nausea not associated with food intake.
No history of vomiting and loose stools.
She also developed shortness of breath occasionally.
Constipation since 3 days.
Then she visited a nearby private hospital where she was investigated and found to have low platlet count 50,000 cells per cubic mm and was referred .
PAST HISTORY:
Patient underwent lateral segment ceaserean section 22 years back.
No H/o Diabetes mellitus, Hypertension, CAD, asthma, epilepsy, tuberculosis.
No previous history of blood transfusion.
DAILY ROUTINE-
Patient usually gets up at 6:00 am in the morning does her household chores, drinks her tea at 8:00am, takes her 1 st meal of the day at 10am in the morning and then works for sometime. Then she takes her lunch at around 3:00am. She takes her dinner at 9 pm and sleeps around 10 in the night .
Personal history
Diet is mixed with normal appetite and regular bladder movements, sleep is adequate, and constipation since 3 days.
Addictions- toddy occasionally.
No known drug allergies.
General examination
Patient is conscious, coherent and cooperative.
Pallor -Present
No features indicating the presence of icterus, cyanosis, clubbing, lymphadenopathy, generalized edema.
VITALS-
Pulse rate 74bpm
Blood pressure 130/80mmhg
Respiratory rate 28cpm
Temperature febrile
No features indicating the presence of icterus, cyanosis, clubbing, lymphadenopathy, generalized edema.
SYSTEMIC EXAMINATION-
CVS- S1 and S2 sounds heard.
RS- Bilateral air entry is present, normal vesicular breath sounds heard.
ABDOMINAL EXAMINATION
INSPECTION
No distention
Scar- LSCS
Umbilicus - Inverted
Equal symmetrical movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.
No local rise of temperature
Abdomen is soft with no tenderness.
No spleenomegaly, hepatomegaly.
PERCUSSION
Liver span is 12cm.
No hepatomegaly
Fluid thrill and shifting dullness absent.
No puddle sign.
AUSCULTATION
Bowel sounds present.
No bruit or venous hum
CNS examination
Higher motor functions intact
No focal neurological deficits noted.
Provisional diagnosis:
Viral pyrexia with Thrombocytopenia &AKI with Acute lung injury.
Investigations:
Hemogram-
LFT:
Serology-
NS1 Ag-Negative
HbsAg-Negative
Anti HCV Antibodies-Non reactive.
Serum Electrolytes-
USG
ECG:
Treatment-
I.V-NS,RL 75ml/hr
Inj.Ceftriaxone 2gm/IV/BD
Inj.Doxycycline-100mg/IV/BD
Inj.Lasix 40mg/IV/BD if B.P>110/70mm Hg
Inj.Neomol 1gm/IV/SOS if temp.>101°F
Inj.Pantop 40mg/IV/OD (Before breakfast)
Inj.Zofer 4mg/IV/SOS
Tab.Dolo /PO/TID
Intermittent BIPAP 4hrly
Intermittent CPAP 4HRLY
Nebulisation -Duolin and Budecort(6hrly)
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