55 YEAR OLD FEMALE WITH HIGH GRADE FEVER ,WEAKNESS SINCE 10 DAYS
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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 diagnosis and treatment plan.
55 year old female resident of pallipadu presented with chief compliants of:
-Fever since 10 days
-Generalised Weakness since 10 days
-Backache since 10 days
-Swelling in legs since 2 days
History of presenting Illness:
Patient was apparently asymptomatic 10 days back then she developed fever which was sudden in onset, continuous, with chills and no rigor ,no evening rise of temperature.
Patient complains of backache since 10 days , continuous which is insidious in onset,pain is confined to shoulder mostly ,dull aching type,non radiating,with no aggravating and relieving factors.
She also has complaints of body pains since 10 days for which she got medication from their local RMP but it is not subsided
As the symptoms didn't subside she went to a government hospital where she was diagnosed with low blood pressure and Decreased platelet and kept under observation.
As her condition doesnt improved she came to our hospital .
The patient is now having Bilateral pedal edema , pitting type up to knee.
Past History:
Patient has no similar complaints in the past
No surgeries underwent into the past
No history of Diabetes mellitus, hypertension, coronary artery diesease,asthma, epilepsy, tuberculosis.
Personal History:
Patient takes mixed diet, appetite is decreased, bladder movement is normal, patient complains of decreased bowel movements.
Addictions: Patient consumes alcohol occasionally (1-2pegs).
Patient smokes chutta since 40 years 1-2 per day.
Patient has no known allergies
Family History:
No significant family History
Treatment History:
Antipyretics , Antibiotics (unknown)
General Examination
Patient is conscious coherent coopertive well oriented to time, place and person. She is well built and well nourished.
Vitals:
Temperature: afebrile
BP- 90/70 mmHg
Pulse-80 beats per minute
RR- 15 cpm
Pallor : present
Icterus :Absent
Cyanosis- absent
Lymphadenopathy-absent
Clubbing-absent
Generalised edema- absent
Bilateral pedal edema - seen
Systemic Examination:
Abdominal Examination -
On Inspection:
Abdominal Distension is present
Umbilcus is at centre (slit like)
No dilated veins
No scars,sinuses.
Palpation:
No local rise in temperature
Tenderness is elicited in the Right Hypochondrium .
No visible pulsations
No organomegaly
Percussion: No Significant Findings
Auscultation:
Bowel sounds heard
Cardiovascular system:
S1 S2 heard ,no murmurs
Respiratory system:
Bilateral Air entry present
Normal vesicular breath sounds heard
Central Nervous system:
Higher mental function intact
No focal neurological deficit
Provisional Diagnosis:
Dengue shock syndrome with Thrombocytopenia , Acute Kidney injury ,Acute Liver injury.
Investigations:
Fever chart
2/1/23
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