70 Year old female patient with fever bodypains and vomitings

 This is an E log book to discuss our patient's de-identified health data shared after taking his guardian sign informed consent.Here we discuss ou individual patient problems through series of inputs from available  global online community of experts with an aim to solve those patient's clinical problem with collective current best evidence based inputs.This e log book also reflect my patient centered online learning portfolio.


A 70 year old female came to OPD with the chief complaint of fever, vomitings and body pains since 2 weeks.

Patient was apparantly asymptomatic 2 weeks back and she reffered to a local clinic and a week back was shifted to our hospital.

Patient had fever which was intermittent ,continuous and decreased with medication.and also burning micturition.

She had burning sensation of feet and lower limbs.She had vomittings on consumption of food 4 times a day and food particles as content.Patient has loose stools and dryness of tongue.She has pain in inner buccal mucosa,swelling and pain during swallowing.patient has breathlessness.

Daily routine.

She is a housewife and used to wake up at 6:30 am and go for a walk for 1hour .She used to take ragi jowar ,chapati,rice.


PAST HISTORY:

Patient was takes previously to other hospital for the same cause and was examined and found that platelet count was 22,000. 

Hemoglobin level-11.

WBC was 4600

She was diagnosed to have viral fever.

Known case of diabetes and hypertension since 10 years.Not a case of epilepsy,asthma,TB.


PERSONAL HISTORY


Diet: mixed 


Appetite: normal 


Sleep: inadequate 


Bowel movements: normal 


Addictions: none 


GENERAL EXAMINATION

Patient is conscious, coherent, cooperative,well oriented to time,place and person.

No signs of clubbing, cyanosis.


VITALS 


Temperature-99 F 


BP-120/80mmhg 


Pressure-89bpm 


Rr-16cpm 


Spo2-98% on RA 


GRBS-234mg% 


SYSTEMIC EXAMINATION

Rs-bae+, normal vesicular breadth sounds 

Cvs-S1 S2+,no murmurs heard.













PROVISIONAL DIAGNOSIS

DENGUE 


TREATMENT

IVF NS 

Injection neomol 

Tab dolo 

Tab glimiperide 

Tab metformin.










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