Medical case disscussion
July 23,2022
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Name : Mounika 8th sem
Roll no : 46
I have been given this case to solve an attempt to understand the topic of "patient clinical analysis data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan
CASE DISCUSSION
A 21 year old female patient from Islamilpalli, who's a Bsc nursing student came to the casuality with chief complaints of
•Fever since 10am on 21/7/22
•Body pains
•Vomitings since 21/7/22 evening
•History on non-productive cough
HOPI :
A 21 year old female patients presenting with fever,insidious in onset,high grade,continous,associated with chills&body pain since 10 am 21/7/22
H/o Vomitings on 21/7/22 evening 6 episodes , non bilious type,non-projectile, food particles and water as content,was associated with abdominal pain(h/o Outside food intake - corn,chicken on 20/7/22)
No H/o loose stools
No H/o cold,burning micturation,ear ache,tinnitus,shortness of breath,chest pain,palpitations,diarrhoea,eye pain
Daily routine :
Wakes up at 7 am,do her regular activities,have breakfast and attend college classes,clinicals,have lunch at 1pm and attend college from 2-4pm , and having snacks on road side frequently, goes to bed at 10pm
Past history :
Not a k/c/o diabetes/ hypertension/asthma/CAD/CVA/Epilepsy/Typhoid/Thyroid disorders
No previous surgical history.
Personal history :
•Diet : mixed
•Appetite : decreased since yesterday
•Sleep : distributed sleep because of chills and rigor
•Bowel movements :
Vomitings since yesterday evening
•Bladder movements: Regular
•Addictions : None
Allergies :
Allergic to potato , Roselle leaves and brinjal
Family history : not significant
Menstrual history :
Age of menarche : 12
Duration of mensuration : 5 days
LMP : 25/6/22
Regular : 5/30
No other Gynecologic problems
Immunization status :
Vaccinated up to date
Vaccinated for covid -19
GENERAL EXAMINATION •Patient is examined in a well lit room after obtaining consent
•Patient is conscious, coherent, cooperative.
Well built and well nourished.
•Height -5'2
• Weight - 55 kgs
•Pallor , Icterus,clubbing, cyanosis, koilonychia, edema are absent
•VITALS
Temp- Afebrile (100 f)
Bp-100/80 mm hg
PR- 84bpm
RR-16CPM
Spo2- 99% on RA
GRBS : 102
SYSTEMIC EXAMINATION
RS- bilateral air entry present
CVS : S1, S2 + no murmurs
P/A- soft and non tender
bowel sounds present
CNS : No focal neurological defeicit
HMF intact
Power in B/L upper and lower limb Is 5
Reflexes are present with B/L plantars and flexors
INVESTIGATIONS :
On 22/7/22
*COMPLETE URINE EXAMINATION :
*APTT
*BLEEDING AND CLOTTING TIME
*BLOOD FOR M.P.-STRIP TEST
*BLOOD GROUPING AND Rh TYPING
*Fever chart showing continuous type of fever.
*
ECG* RASH
"On 23/7/22"
*USG Report
*Record of Temp,BP,RR &SPO2
"On 24/7/22"
*Haemogram
6 : 30 am
"On 25/7/22"
*Hemogram
(9 am)
(7pm)
*Record of Temparature,BP, RR AND SPO2
*USG Abdomen
"On 26/7/22"
*Haemogram
*Blood Urea
*Serum Creatinine
*Serum electrolytes & Serum Iodized Calcium
*Fever chart
* Investigation chart
"On 27/7/22"
*Haemogram
No fever spikes since yesterday
C/o pain in abdomen (subsided)
Pt is c/c/c
Bp:-110/60 mm hg
Pr:- 72 bpm
Spo2:-98%
Cvs:-s1 s2 +
R/s:- Blae +
P/a:- soft , tenderness over right hypochondrium
Cns:-Nad
Tlc:-4000 cells/cumm
Platelets:-70000 /cumm
Treatment on 27/7/22
-iv.fluids @75ml/hr -Ns,Rl
-inj.Neomol 100ml/iv/sos
-tab. Pan 40mg/po/od
-inj.tramadol 1amp/iv/sos
*Clinical Images
*Chest X-ray PA view
*Palate showing petechiae
COURSE IN THE HOSPITAL:
A 21 year female presented to the casuality with above mentioned complaints. Upon admission initial examination was done, Hess test was negative; No postural drop; Necessary investigations were done. Dengue for NS1 Ag was positive with negative IgM and IgG; TLC 4800 and Platelets 1.3 L. She was started on IVF and advised to drink plenty of oral fluids. On day 2; she c/o body pains, started having menses associated with Dysmenorrhoea; abdominal pain was decreased; Oral Mefenamic acid was started and IVF and NEOMOL were continued. USG Abdomen was done, which showed no sonological abnormality. On day 3; she had c/o dry cough, headache, Dysmenorrhoea and along with fever spikes. Urine and Blood were sent for Culture and sensitivity. Upon examination postural drop was 18mmHg; PP 34mmHg; on ausculation of lung fields- decreased breath sounds on the Right IAA and ISA when compared to Left lung fields. 1 Unit of SDP transfusion was done on day 4, 1:30 AM i/v/o petechiae and heavy menstrual bleeding. USG Abdomen was done which showed Gall bladder wall edema, Grade I fatty liver, Minimal Ascites at pelvic and perihepatic space. Hess test was negative, No postural drop. She was started on Oral Tranexamic acid + Mefenamic acid.
*PROVISIONAL DIAGNOSIS :
• DENGUE WITH THROMBOCYTOPENIA AND LEUCOPENIA
*TREATMENT :
✓ Plenty of oral fluids
✓IVF ( NORMAL SALINE , RINGER LACTATE
75 ml / hr )
✓ Inj Xone 1gm IV /BD
✓Inj Mifenac MR PO / BD
✓Tablet okacet 10 mg/PO/BD
✓Tablet Doxy 100mg/PO/BD
✓Tablet metaspas PO / BD
✓Inj Neomol IV /SOS
✓ Tablet PCM 600 mg PO / TID
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