55yr old with viral pyrexia
E-LOGS GENERAL MEDICINE
Roll no 04
Hi, i am lasya, 5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. Hope this will be informative!
* This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.
A 55yr old female patient came to OPD with complaints of fever associated with chills and rigor , vomitings, burning micturition , burning sensation of both feet , backpain not radiating to legs and black stools .
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 months ago when she had recurrences of fever very frequently , not associated with chills .
Fever usually got subsided with use of medication (dolo 650) .
They then visited a diagnostic centre for CBP where they were said to have low platelets.(31 ,000)
She came to our OPD with complaints of
* Black stools since 7 days .
* Fever associated with chills and rigors ( on and off) , vomitings ( more than 3 episodes per day ), burning micturition since 3 days .
* C/o burning sensation of both feet , backpain not radiating to legs since 3 days .
PAST HISTORY:
k/c/o diabetes since 1yr
Not a k/c/o hypertension
Surgical history: appendectomy , hysterectomy.
PERSONAL HISTORY:
Diet : mixed
Appetite: normal
Bladder and bowel movements: normal
Addictions : no history of alcohol consumption and tobacco usage.
Sleep : decreased
FAMILY HISTORY:
NO significant family history.
GENERAL EXAMINATION:
Moderately built and nourished .
*Pallor - slightly seen
* Icterus -not seen
* Cyanosis -not seen
*Clubbing -not seen
*Lymphadenopathy -not seen
*Oedema -not seen
VITALS :
*Temperature - 103.8°F
*Pulse rate - 118/ min
*Respiratory rate - 20 /min
*BP - 150/90 mm Hg
*SpO2 - 97%
*GRBS - 226mg%
SYSTEMIC EXAMINATION:
CVS :
S1 and S2 heard
No thrills and murmurs .
Respiratory system:
BAE +
no wheeze and dyspnea
Position of trachea - central
Breath sounds - vesicular
ABDOMEN:
Shape - obese
Soft and non tender
No palpable masses
No free fluid
No bowel sounds
CNS :
NAD
*conscious and alert
*Speech is normal
*No signs of meningeal irritation
PROVISIONAL DIAGNOSIS:
viral pyrexia associated with thrombocytopenia.
Clinical malaria .
INVESTIGATIONS :
TREATMENT:
Conservative
1) TAB . DOXYCYCLINE 100mg PO/BD
2) IV fluids NS RL 100ml/hr
3) INJ PAN 40mg IV/BD
4) TAB DOLO 650mg QID
5) TAB NITROFURANTOIN 100mg PO/BD
6) SYRUP CITRALKA
7) GRBS MONITORING 6th hrly
8)INJ HAI SC TID
9) INJ FALCIPO 120mg Iv
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