57 yr female with fever , thrombocytopenia

 September 3rd ,2022

This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.


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 a diagnosis and treatment plan.  

57yr old female patient came to the casuality   with chief complaints of  

 C/o fever since 4days

C/o vomitings since 4days 

C/o chest pain since 3days 

C/o loose stools since 3days 

C/o sob since 1day 

HOPI: 

Patient was apparently asymptomatic 4days ago 

Later developed fever insidious in onset intermittent associated with chills, generalised body pains and headache 

H/o vomitings since 4days (4to5 episodes per day) non bilious, non projectile and food as content.

H/o chest pain since 3days non radiating and not associated with palpitations,giddiness.

H/o loose stools since 3days and sob since 1day 

No h/o cold, cough, abdominal pain, burning micturition. 

Past history:  

K/c/o HTN since 1year (on medication-not known)

Not a k/c/o DM,TB, ASTHMA,CAD, EPILEPSY. 

Personal history: 

Diet: mixed 

Appetite: normal

Sleep: adequate 

Bowels: regular 

Micturition: Normal 

No Addictions  

Family history: 

Not significant 

General examination: 

Patient is c/c/c 

Vitals: 

Afebrile 

Bp: 120/80mmhg

PR: 90bpm

RR: 16 cpm

No Pallor 

No icterus 

No cyanosis 

No clubbing 

No lymphadenopathy 

No edema 

Systemic examination: 

CVS: S1 S2 sounds heard 

RS: BAE+,clear 

P/A :Soft and non tender 

CNS:NAD 









Fever chart






Chest x-ray




ECG


USG 




Hemogram on 1/09/22 morning


Blood group and Rh typing-B positive 

RBS-88mg/dl

Blood urea:40mg/dl  

Serum creatinine:1mg/dl 


LFT on 1/09/22



LFT on 3/09/22

Serum electrolyte on 1/09/22

Serum electrolyte on 3/09/22



Hemogram on 1/09/22 evening 

Hemogram on 2/09/2022
 



Diagnosis: 

Dengue NS1 positive with thrombocytopenia with hepatitis

Treatment: 

1)IV fluids NS and RL 100ml/hr 

2)Inj.Optineuron 1amp in 100ml NS 

3)Inj.Pan 40mg /IV /OD 

4)Inj.Zofer 4mg /IV /SOS 

5)Tab.Dolo 650mg /PO /TID 

6) Inj.Doxy 100mg IV /BD 

7) inj.Neomol 1gm /IV /SOS (If temp >101F)

8)strict I/O charting 

9)W/F bleeding manifestons 








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