A 50 yr old female with fever and abdominal distension

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 available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs


50 year old female came to OPD with chief complaints of 

                •Fever since 6 days 

                 •Abdominal pain and distension                                        since 6 days,

                 •Burning micturition since 3 days

                 •Vomitings


HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 6 days back then she developed fever which is insidious in onset, continuous associated with chills and subsided when taken medication . Abdomen is distended and non tender , associated with pain which is dragging type and on palpation liver is enlarged . Petechiae are present on the abdomen in the right hypochondrium region.

Vomitings 2-3 episodes per day non projectile and non blood stained since 5 days . Patient complaints of burning micturition since 3 days with shortness of breath (grade 2). 











Asymptomatic hypopigmented patches were found over both forearms since 15 years which were not increasing in size and there is no loss of sensation over lesions at present.she is referred to dermatologist.
There is history of loss of sensation over the lesions in the past for which she used medication for 6 months.







No c/o of cough, cold , bilateral pedal edema, headache, giddiness


PAST HISTORY

Patient is not a k/c/o diabetes mellitus, hypertension, epilepsy, asthma,CAD, CVA.

H/o MDT therapy taken for 6 months in the past


PERSONAL HISTORY

Diet --mixed 

Appetite - normal 

Bowel and bladder movement -- regular

Sleep - adequate 


FAMILY HISTORY

No significant family history


On Examination : 


Patient is conscious , coherent , cooperative


Temperature : afebrile (98.8.f)


BP : 110/90 MMhg 


pulse rate : 100beats per minute


Respiratory rate : 18 cycles per minute


SPO2 : 96%


No signs Pallor , ictreus , cyanosis , clubbing , lymphadenopathy, edema of feet




 System examination : 

Cvs : s1,s2 heard , no murmurs

Rs : bae+


Investigations :


HEMOGRAM: 


HB: 13.8

TLC: 3,700

N/L/E/M/B: 45/46/01/08/00

PCV: 40.9

MCV: 109.5

MCH: 36.9

MCHC:33.7

RBC:3.74

PT:8000

RDW-CV :13.5

RDW-SD: 56.2

PS: NC/NC


Ultrasound report




2D ECHO







ECG






Provisional diagnosis : 

Dengue NS1 antigen positive


Treatment : 
ivf - ns and rl @ 100ml/hr
Inj. Pantop 40 mg/iv/od
Inj. Zofer 4 mg/iv/sos
Inj. Neomal 100ml ( if temp > 101.1.f) iv/sos
Tab. Mvt /po/od
Fever charting hourly 
Bun,plv daily

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