A 60 year old female with fever since 15days

This is an online E log book 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 available global online community of experts with an aim to solve those patient's 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 is welcome.

Case presentation:

A 60 yr old female who works in heritage was apparently asymptomatic 15 days back then she developed fever which was high grade, intermittent. So she went to RMP who said her BP was low and used medications( records not available) and got relieved with medication. Then patient was afebrile upto 8 days, after which she went to work for 2 days and then she again developed fever  , intermittent type, relieving with medication. patient went to an another RMP doctor( where platelets were 9,000). 
Patient came to KIMS for further evaluation.
There is a history of 1 episode of vomitings which was non blood tinged and non bilious.
No history of SOB , palpitations, dizziness, pedal edema.
No history of pain abdomen.

Past history:- Not a known case of DM, HTN, CAD, CVA, TB, Asthma
No h/o any previous  blood transfusions  and surgeries.

FAMILY HISTORY :No H/O similar complaints in the family

PERSONAL HISTORY:

 He was on mixed diet, appetite normal, bowel and bladder habits regular and occasionally toddy drinker (since 30 years, approx 250ml)

GENERAL EXAMINATION: 

 pt is conscious, coherent, cooperative and oriented to time, place and person  mildpallor 

no Icterus,cyanosis,clubbing, lymphadenopathy,edema

VITALS:

Temperature-99.8°f on presentation 

BP:140/90mmhg

PULSE:82bpm

RR:19cpm

Spo2:98%

GRBS:98mg/dl

Systemic examination:-

CVS- s1 s2 heard,no murmurs

RESPIRATORY SYSTEM -bilateral air entry present , + normal vesicular breath sounds. no added sounds

PER ABDOMEN-

       Scaphoid in shape,no tenderness and no palpable mass present.Hernial orifices are free.Liver and spleen are not palpable.Bowel sounds are present.

CNS:

all higher motor functions are normal

Cranial nerves intact

Sensory system normal

Motor system normal

Cerebellar signs normal

No meningeal signs

Investigations:-

                   Serum creatinine


               Random blood sugars

                        hemogram

                               CUE

                  Dengue NS1 antigen

                        Chest x- ray

                          blood urea

                  serum electrolytes


PROVISIONAL DIAGNOSIS:
Fever with thrombocytopenia 
Denovo hypertension 

On day 2:-

1 fever spike in morning

No complaints of nausea, abdominal pain

Complaints of coffee colored sputum( mucopurulent)

Vitals:-  BP :- 140/90 mg

              PR:- 82bpm

              CVS: -S1S2 heard

              RS:- BAE+, clear

              P/A:- soft

              GRBS:- 98mg/dl

              I/O :- 1700/500

Investigations:- 

                 Ultrasound abdomen

                             2d echo


                              ECG

                      Hemogram



Treatment:-

IVF- NS, RL @ 100ML/ he

Tab. PCM 650 mg po/sos

Inj.PAN 40mg iv/OD

INJ.ZOFFER 4MG IV/BD


 On Day 3:-

Complaints of hematuria and headache

Vitals:- Bp:- 160/100 mmhg

             PR:- 70bpm, regular

              CVS:- S1S2 +

              RS:- BAE+

             SP02:- 97% ON RA

              I/O:- 36OO/1450

             RR:- 29/ MIN

             GRBS:-131 MG/DL

INVESTIGATIONS:-

                           Hemogram

                               CUE

TREATMENT:-

                IVF- NS ,RL @ 100ml/hr

                Tab. PCM 650mg po/sos

                Inj.PAN 40mg iv/of

                Inj. Zoffer 4mg iv/sos

               Plenty of oral fluids

              1 SDP transfusion


Day 4:-

    Complaints of petechiae on both legs

    Fever spike 1 episode

Vitals- BP - 130/90 mmhg

           PR- 102 bpm

          CVS - S1S2 heard

          RS- BAE+ , clear

          P/A - soft

Investigations:- 

                       Hemogram

TREATMENT:-

                    IVF- NS ,RL @ 100ml/hr

                   Tab. PCM 650mg po/sos

                   Inj.PAN 40mg iv/of

                  Inj. Taxim 1g iv/bd

                  Plenty of oral fluids

                 1 SDP transfusion

                  Tab. Doxy 100mg po/bd


Day 5:-

No fresh complaints

Vitals:- BP:- 160/90 mmhg

             PR:- 84bpm, regular

             GRBS:- 97 mg/do

             I/O :- 3100/1100

                




                

                   

                              

                   

               


          


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