17 y/o female with complaints of sudden fever

 Note : This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Here, in this series of blogs, we discuss our various patients' 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.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. 

I have been given the following case to solve, in an attempt to understand  the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings,  Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

Name : M.Aishwarya

Roll No : 89

Case Scenario : A 17 year old female, who is a college student by profession, has been brought to the OPD with chief complaints of 

• Fever - since past 3 days
• Vomiting - since past 3 days
• Tiredness - since past 3 days

History of present illness : 

• Patient was apparently asymptomatic 3 days ago, when she developed a sudden episode of high grade fever, not associated with chills and rigor.
• Fever was continuous for 1 whole day and subsided on taking medication
• Patient had one bout of vomiting in the whole day, no medication given
• Associated generalized weakness was present for 1 day.
• After 1 day of high grade fever, patient decided to get admitted in a local hospital and then got admitted here.
• No H/O shortness of breath, chest pain, palpitations
• No H/O pain abdomen, loose stools
• No H/O burning micturition, 
• No H/O cough, cold.

Past History : Not significant

Personal History :

• Marital status - Single
• Occupation - College student
• Appetite - Normal
• Diet - Mixed
• Bowels - Regular
• Micturition - Regular
• Sleep - Regular 
• Known allergies - None
• Habits/addictions - None

Family History : Not significant 

Treatment History : Not significant

PHYSICAL EXAMINATION

A. General

• Pallor - No
• Icterus - No
• Cyanosis - No
• Clubbing of toes/fingers - No
• Lymphadenopathy - No
• Oedema of feet - No
• Malnutrition - No
• Dehydration - No
• Pulse rate - 65 beats/min
• Respiratory rate - 14 breaths/min
• Blood pressure - 120/70 mmHg
• SpO2 at room air - 100%
• GRBS - 98 mg%
• No birth deformities seen

B. Cardiovascular system

• Thrills - No
• Cardiac sounds - S1,S2
• Cardiac murmurs - none

C. Respiratory system

• Dyspnoea - No
• Wheeze - No
• Position of trachea - General
• Respiratory sounds - Vestibular
• No abnormal sounds detected

D. Abdomen

• Shape of abdomen - Scaphoid
• Tenderness - None 
• Palpable mass - None
• Hernial orifices - None
• Free fluid - None
• Bruits - None
• Bowel sounds - None
• Spleen and Liver - Not palpable

E. CNS

• Patient is conscious, coherent with normal speech
• No signs of meningeal irritation
• Normal sensory system, motor system, cranial nerve functioning observed.
• Normal reflexes, cerebellar functioning and gait seen.

PROVISIONAL DIAGNOSIS : Viral pyrexia with thrombocytopenia.

INVESTIGATIONS :

                   COLOR DOPPLER/2D ECHO

ECG

TREATMENT :

Day 1

• IV fluids : NS 100ml/hr, RS 100ml/hr
• Inj. NEOMOL 1 gm IV/SOS
• Inj.PAN 40 mg IV/OD
• Inj.ZOFER 4 mg IV/SOS
• Tab.PCM 650mg PO/TID
• Water for bleeding manifestations
• Monitor vitals