Dengue hemmoragic fever and thrombocytopenia
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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.
D. Shreeya , 8th sem ,roll no 39
A 21years old female resident of ismanpalli.student by occupation came to OPD with a cheif complaints of
.fever since 21/7/22
.body pains since 21/7/22
.vomiting since evening 21/8/22
History of presenting illness
The patient was apparently asymptomatic 1day back then she developed fever which is insidious in onset,high grade, continues ,relieved by taking pace tamil and associated with chills and rigors
History of body pains since 1 day
History of vomiting since 21/7/22.6 episodes per day which is non billions,non projectile,consists of food particals and watery,which is associated with abdominal pain
History of headache in the frontal region
No History of cold ,burning mitcuration, earache, ringing sensation, SOB,chest pain,palpitations, diarrhea, eye pain
No History of intake of junk food 2days before the onset of symptoms
Daily routine
She wakes up in the morning 7am and the she will have the regular activity and have lunch by 8 am and goes to the college (BSc nursing)have lunch by 1pm and come back to hostel by 5 in the evening and have Daily routine and have dinner by 8pm and sleep by 11pm
Past History
Not a known History of diabetes, Hypertension, thyroid, asthama, Tuberculosis, Epilepsy
Had a blood transfusion on 25/7/22
Personal History
diet -mixed
Appatite-decresed since
Sleep-adequate
Bowel and bladder-regular
No addictions
She is allergic to potato,brinjal, carrots she fell itching all over the body and rashes are see after eating
Family History
Not significant
Menstrual History
She is having a regular cycle
Age of menarche-12yr
No.days of bleeding-5days(3day heavy flow and next 2 days normal flow)
LMP 25/6/22
Dysmenorrehea present
No other gynecological problem
General examination
The patient was consious, coherrent, co operative well oriented with time, place,person Moderately built and nourished
No pallor
No pedal edema
No clubbing
Vitals
Temp-febrile(100 F)
Bp-100/80mm of Hg
PR 84bpm
RR 16Cpm
Spo2 97%
GRBS-102
SYSTEMIC EXAMINATION
RS-B/L air entry is present and vesicular breath sounds are heard
CVS-s1 and s2 sounds heard no murmurs
P/A-soft non tender and bowel sounds are Heard
No focal neurological deficit
All reflex are normal
Investigations
APTT-37sec
Bleeding time-2min
Clotting time-5min
Malaria parasite-absent
Prothrombin time-18sec
INR-1.3
BLOOD GROUP-B(+ve)
Platelet count-
1.3 lakhs/mm3(23/7/22)
80,000/mm3(24/7/22)
50,000/mm3(25/7/22)
26,000/mm3(26/7/22)
40,000/mm3(26/7/22 evening)
Ns1antigen-positive
Hemogram
RFT
X ray
Fever chat
ECG
USG
Clinical pictures
PROVISIONAL DIAGNOSIS :
• DENGUE HEMMORE FEVER WITH THROMBOCYTOPENIA
*TREATMENT :
✓IVF ( NORMAL SALINE , RINGER LACTATE )
75 ml / hr
✓ Inj Xone 1gm IV /BD
✓Inj Mifenac MR PO / BD
✓Tablet okacet PO/BD
✓Tablet Doxy 100mg/PO/BD
✓ plenty of fluids ( oral )
✓Tablet metaspas PO / BD
✓Inj Neomol IV /SOS
✓ Tablet PCM 600 mg PO / TID
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