55 Y/F with fever and generalised weakness

 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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."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 a diagnosis and treatment plan


CHIEF COMPLAINTS: 

Fever since 10 days

Generalised weakness since 8 days

Shortness of breath since 6 days

HOPI :

Patient was apparently asymptomatic 10 days back, then she developed fever which is of high grade , intermittent, associated with chills and rigor, no diurnal variation and relieved with medication. Generalized weakness and fatigue since 8 days. Shortnes of breath since 6 days, no orthopnea, chest pain, palpitations, giddiness. Pedal edema present

No H/O cold , cough , vomitings, 

PAST HISTORY:

Not a k/c/o DM , HTN , epilepsy, asthma , CAD , CVD,TB

PERSONAL HISTORY:

Appetite-Decreased 

Diet - Mixed

Bowel and bladder - regular 

Sleep - Decreased.

General examination:

Patient is conscious, coherent, cooperative, well oriented to time , place and person 

Pallor - present

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy- absent 

Pedal edema - pitting type extending till knee 



VITALS :  Temp - 98.6 F

                  PR - 62 bpm

                 BP - 80/50 mmhg

                RR - 32 cpm

                SPO2 - 98% onRA

                GRBS - 102 mg/dl





Systemic examination: 

PER ABDOMEN:

Inspection :

Umbilicus is central and inverted

All quadrants are moving equally with respiration 

No scars , sinuses , engorged veins, visible pulsations .

Hernial orifices are free.

Palpitation :

Abdomen is soft and tenderness present in right hypochondrium

No organomegaly.

Percussion :

Tympanic note heard over the abdomen.

Auscultation:

Bowel sounds are heard.



CARDIOVASCULAR SYSTEM:

Inspection:

        Shape of chest is elliptical.

        No raised JVP

        No visible pulsations, scars , sinuses , engorged veins.

Palpitation:

        Apex beat - felt at left 5th intercostal space

        No thrills and parasternal heaves

Auscultation :

        S1 and S2 heard. 

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.



CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes    Right    Left

Biceps         ++         ++

Triceps        ++         ++

Supinator    ++       ++

Knee            ++       ++

Ankle           ++        ++









PROVISIONAL DIAGNOSIS:

DENGUE SHOCK SYNDROME WITH THROMBOCYTOPENIA WITH PRE RENAL AKI WITH ACUTE LIVER INURY.

1/1/2023 ( DAY 2)
GM UNIT 6
ICU BED 4

S - 
NO FEVER SPIKES

O-
PULSE - 84bpm 

BP -90/60 mmhg on norad 6ml/hr

RR - 28 CPM

SPO2- 98% AT RA
 100% on 4l o2

TEMP - AFEBRILE

CVS - S1 , S2 +

RS - BAE + , NVBS

PA - SOFT , NT.
         NO ORGANOMEGALY 

CNS - NAD



A- 
DENGUE FEVER WITH THROMBOCYTOPENIA WITH AKI ( NON OLIGURIC) WITH ACUTE LIVER INJURY 
DENGUE SHOCK SYNDROME 

P-
IVF - NS WITH 1 AMPOULE OF OPTINEURON 

IVF NS @ 150 ml /hour, 1 DNS 

INJ NORADR -2 ampoules IN 46 ml NS @6 ml/hr

INJ PAN 40 mg IV/OD

TAB PCM 1gm PO/TID

MONITOR VITALS 4th HRLY


2/1/2023 ( DAY 3)
GM UNIT 6
ICU BED 4


S - 

DECREASED APPETITE

NO FEVER SPIKES 

STOOLS PASSED 

O-
PULSE - 86 bpm 

BP -90/60 mmhg on norad 6ml/hr

RR - 26 CPM

SPO2- 98% AT RA
 

TEMP - AFEBRILE

CVS - S1 , S2 +

RS - BAE + , NVBS

PA - SOFT , NT.
         NO ORGANOMEGALY 

CNS - NAD

INPUT - 

OUTPUT-


A- 
DENGUE SHOCK SYNDROME WITH THROMBOCYTOPENIA WITH AKI ( PRE RENAL -NON OLIGURIC) WITH ACUTE LIVER INJURY 


P-

IVF - 1 NS WITH 1 AMPOULE OF OPTINEURON @ 100 ml/hr

IVF NS , RL ,DNS @ 150 ml /hour 

INJ NORADR -2 ampoules IN 46 ml NS @6 ml/hr

INJ. MONOCEF 1gm IV/BD

TAB PCM 650 mg PO/TID

MONITOR VITALS 4th HRLY



3/1/2023 ( DAY 4)
GM UNIT 6
ICU BED 4


S - 

DECREASED APPETITE

NO FEVER SPIKES 

STOOLS PASSED 

O-
PULSE - 96 bpm 

BP - 80/50 mmhg on norad 4ml/hr

RR - 32 CPM

SPO2- 97 % AT RA
 

TEMP - AFEBRILE

CVS - S1 , S2 +

RS - BAE + , NVBS

PA - SOFT , NT.
         NO ORGANOMEGALY 

CNS - NAD

INPUT - 4850

OUTPUT-4300

HAEMOGRAM:

         Hb – 9.7 gm/dl

         TLC – 6700cells/cu mm

         PLC - 16000


RENAL FUNCTION TESTS :

         Urea : mg/dl

         Creatinine : mg/dl

         Sodium : 140 mEq/L

         Potassium : 6.6 mEq/L

         Chloride : 105mEq/L


A- 
DENGUE SHOCK SYNDROME WITH THROMBOCYTOPENIA WITH AKI ( PRE RENAL -NON OLIGURIC) WITH ACUTE LIVER INJURY 


P-

IVF - 1 NS WITH 1 AMPOULE OF OPTINEURON  @ 100 ml/hr

IVF NS , RL ,DNS @ 150 ml /hour 

INJ NORADR -2 ampoules IN 46 ml NS @4 ml/hr

INJ LASIX 20 mg IV OD ( IF SBP >110 mmhg)

TAB DOXY 100 mg PO/BD

MONITOR VITALS 4th HRLY


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