A 55 year old female with fever and pain abdomen
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I have 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.This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
Maheshwari Jagathkari
Roll no 57
Case report
A 55 year old female tailor by occupation with chief complaints of
Fever, generalized body weakness, pain abdomen since 4 days.
Shortness of breath since 4 days.
Constipation since 3 days.
HOPI
Patient was apparently asymptomatic 4 days back.
Then she developed fever which was continuous in nature associated with chills and rigors, headache, generalized body weakness, and relieved on taking medication.
Pain abdomen was diffuse in nature which is dragging type, non radiating and associated with nausea not associated with food intake.
No history of vomiting and loose stools.
She also developed shortness of breath occasionally.
Constipation since 3 days.
Then she visited some private hospital where she was evaluated and found to have low platlet count 50,000 cells per cubic mm and was referred to our hospital.
History of past illness
Patient underwent lateral segment ceaserean section 22 years back.
DAILY ROUTINE-
Patient usually gets up at 6:00 am in the morning does her household chores, drinks her tea at 8:00am, takes her 1 st meal of the day at 10am in the morning and then works for sometime. Then she takes her lunch at around 3:00am. She takes her dinner at 9 pm and sleeps around 10 in the night .
Past history
No H/o Diabetes mellitus, Hypertension, CAD, asthma, epilepsy, tuberculosis.
No previous history of blood transfusions.
Personal history
Diet is mixed with normal appetite and regular bladder movements, sleep is adequate, and constipation since 3 days.
Addictions- she consumes toddy occasionally.
No drug allergies.
General examination
Patient is conscious, coherent and cooperative, well oriented to time, place and person.
Pallor is present.
No features indicating the presence of icterus, cyanosis, clubbing, lymphadenopathy, generalized edema.
Vitals
Pulse rate 74bpm
Blood pressure 130/80mmhg
Respiratory rate 28cpm
Temperature febrile
Fever chart
Systemic examination
CVS- S1 and S2 heart sounds heard.
RS- Bilateral air entry is present, normal vesicular breath sounds heard.
ABDOMINAL EXAMINATION
INSPECTION
No distention
Scar- LSCS
Umbilicus - Inverted
Equal symmetrical movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.
PALPATION
No local rise of temperature
Abdomen is soft with no tenderness.
No spleenomegaly, hepatomegaly.
PERCUSSION
Liver span is 12cm.
No hepatomegaly
Fluid thrill and shifting dullness absent.
No puddle sign.
AUSCULTATION
Bowel sounds present.
No bruit or venous hum
CNS examination
Higher motor functions intact
No focal neurological deficits noted.
Provisional diagnosis
Viral pyrexia with acute kidney injury.
Investigations
Anti HcV antibodies - Non reactive
Liver function tests
Prothrombin time- 18 sec (normal range 10-16 sec)
Serum electrolytes
USG
Treatment
IV RL, NS 75ml/hr
Inj.Ceftriaxone 2gm/IV/BD
Inj.Doxycycline100mg/IV/BD
Inj.Lasix 400mg/IV/BD if BP greater than 110/70mmHg
Inj.Neomol 1gm/IV/SOS if temp greater than 101 F
Inj. PAN 40mg/IV/OD before breakfast
Inj.Zofer 4mg/IV/SOS
Tab.Dolo 650mg/PO/TID
Intermittent BiPAP 4th hourly
Intermittent CPAP 4th hourly
Nebulization- Duoline, Budecort 6 hourly
SOAP notes
S:
body pains decreased SOB decreased
O:
no fever spikes
O/E
Pt is C/C/C
Bp: 130/80mmhg
PR: 90bpm
CVS: S1S2 +
RS: BAE +
CNS: NAD
A:
viral PYREXIA with thrombocytopenia
P:
1. IVF NS RL @75ml/hr
2. Inj. Ceftriazone 1gm/IV/BD
3. Inj. Pan 40mg IV/OD
4. Inj. Zofer 4mg IV/SOS
5. T. Dolo 650mg PO/TID
6. Intermittent BIPAP 4th hourly
7. NEB- DUOLINE & BUDECORT - 6th hourly
8. Strict BP, PR, Temp monotoring 4th hourly
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