Dengue fever
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
K.shirisha
Rollno;60,
9th semester
55 year old female occupation by housewife resident of Suryapet came to opd on 10/3/22.
Chief complaints ;
Fever since 4 days
History of present illness;
The patient was alright 4 days back then she had fever which was high grade , insidious in onset, continuous in nature.associated with chills and rigor and sweats.
No diurnal variations and aggrevating and relieving factors
* She had giddiness and had syncope attack on9/3/22.
C/o vomiting 1 episode which were non bilious ,containing food as particles.,non projectile.
C/O body pains,loss of appetite ,
No c/o hematmesis,melena, bleeding gums,sob, burning micturition.
C/o abdominal pain which was on and off.
2years ago she had giddiness and visited local hospital and diagnosed as hypertension .she was on atenolol 50mg po/od
3 years ago she had generalised itching all over the body. And facial puffiness .when shewas taking fish,egg, chicken . And when ever she exposed to sun she had itching all over the body.
She has history photosensitivity
Itching was more in dorsum of hand and around the neck .
She visited local hospital and she didn't remember about what docter had said.she was using tab prednisolone since 3years.
Past history ;
Hysterectomy was done 10 years ago
Not k/c/o diabetes,asthma,tb, epilepsy, thyroid and heart disorders
Personal history;
Appetite; decreased since 4 days
Diet : mixed
Bowel and bladder; regular
Sleep ; adequate
No addictions.
Family history; insignificant
General examination;
The patient is conscious, coherent,cooperative, moderately built and nourished
Vitals;
Temperature;
Blood pressure;120/80 mmhg
Heart rate; 75bpm
Respiratory rate;
Spo2; 98%@room air
Pallor
Icterus absent
Cyanosis absent
Clubbing absent
Lymphadenopathy absent
Edema absent
Systemic examination;
On examination;
Dermatology referral notes;
Multiple erythematous,hyperpigmented plaques over exposed areas of face, upper limb and upper chest and lower limb and nape of neck.
Excoriation marks present
Diagnosis; photodermatitis
Hyperpigmented plaques over neck
mature cataract on left eye
mulitple erythematous rashes on cheeks
Per abdomen;
Inspection;
Shape of abdomen ; slightly distended
Umbilicus ; central
No visible pulsations,engorged viene,no visible peristalsis
Movements equal on respiration
Skin over abdomen normal
Palpation;
Tenderness absent
No loacl rise of temperature
No organomegaly
Percussion:
Resonant note heared
Auscultation; bowel sounds were heared
Respiratory system;
Bilateral air entry present,trachea is in central position.
Normal vesicular breath sounds were heared
Cardiovascular system;
S1,S2 heart sounds heared.
Central nervous system;
Higher mental functions;
Leave of consciousness ; normal
Speech: normal
No meningeal signs
Cranial nerve s : intact
Provisional diagnosis; fever under evaluation
Investigations;
USG abdomen
ecgDiagnosis; Dengue fever
Treatment;
✓ iv fluids NS or RL @100ml/hr
✓ inj pan40mg od iv
✓ inj neomol1 gm iv sos ( if temp >101°f)
✓ tab dolo650 po
✓ inj optineuron 1 ampoule in100ml ns od
✓ w/f bleeding manifestations and postural hypotension
✓ temperature charting 4th hourly
✓ Grbs charting 12th hourly
✓cebhydra lotion/ liquid paraffin
✓ tab Teczine 10 mg od 2 weeks.
On 12/3/22
No fever and no bleeding manifestations
Vitals
Temperature; afebrile
Bp; 140/100mmhg supine and standing position
PR: 80bpm
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