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

ecg

2d echo

Diagnosis; 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