30 F PYREXIA AND VOMITING.

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 global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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.
  
A 30 yr old female resident of Miryalguda presented with
 Chief complaints:
        Fever since 10 days and vomiting since 8 days.
History of presenting illness:
    Patient was apparently asymptomatic 10 days back then she developed fever which was insidious in onset and gradually progressive.
Fever is relieved for short time after medication.
Vomiting consists food contents, non bilious and non projectile.
No h/I of rash, pain abdomen, headache, retro orbital pain.
  Past History: 
No similar complaints in the past.
H/o thyroid disorder sice 3 yrs.
N/k/c/o DM, HTN, TB, Leprosy, Epilepsy, CAD, Asthma.
Family history:
     Her father had Diabetes.
Personal history:
       Diet: Mixed
       Sleep: Adequate
       Appetite: Normal
       Bladder and bowel: normal and regular
       Addictions: Nil
       No allergies.
Menstrual history:
        Age of menarche: 12 yrs
        LMP : 18/8/23
        She had blood clots measuring approximately 3x3 cm in her recent mensus 
Treatment history:
      
       Tab. Thyronorm 25mcg once daily.

 General Examination:
      Patient is conscious, coherent and cooperative.
Well oriented to time and place.
No pallor.
No Icterus.
No cyanosis.
No clubbing.
No koilonychia.
No lymphadenopathy
No pedal oedema.
VITALS: 
     Temp: 99.1°F
     Pulse: 80 bpm
    RR: 18 cpm
    BP: 120/80.

Systemic Examination:
  
Cvs:
   S1 , S2 heard 
No murmers
No thrills.
Respiratory: 
      Normal vesicular breath sounds heard.
      No wheeze.
      No dyspnea
       Trachea is central.
CNS:
     C/C/C
      Speech is normal.
      No neck stiffness
      Kernig's sign negative.
       Cranial nerves: intact.
       Motor : intact 
        Sensory:  intact
REFLEXES: 
         
      Biceps: 
            Right: +2
              Left: +2
       Triceps:
           Right: +1
            Left: +1
        Supinator:
            Right: +1
             Left: +1
         Knee
            Right: +2
             Left: +2
         Ankle 
             Right:+1
              Left:+1

 Per abdomen: 
shape of abdomen: scaphoid
Soft and non tender.
no palpable mass
no free fluid
liver & spleen not palpable
No organomegaly.

Gait: normal
Musculoskeletal system: normal
skin: normal.

INVESTIGATIONS:
       USG: 
          
           5 mm calculus is noted in tha gall bladder.
         Gall bladder wall oedema.
         No ascites.
         No lymphadenopathy.
ELISA: 
   NS1 antigen positive 

Provisional diagnosis:
     Viral Pyrexia with Thrombocytopenia.
     NS1 antigen positive with cholelithiasis.
Treatment:
       
 On 20/8/23
      Inj Neomal 1g intravenous.
      Inj Pantop 40 mg intravenous
      Tab   Dolo 650 mg twice.
On 21/8/23
        Inj Neomal 1g intravenous.
        Inj Zofer 4 mg intravenous.
        Tab Dolo 650 mg twice .
         Tab Thironorm 25mcg 
         Tab pause-mf once 
On 22/8/23
            IV Fluids 20 NS
                        10 RL 75ml/hr.
            Inj Neomal 1g intravenous.
            Inj Zofer 4 mg intravenous.
            Tab Dolo 650 mg twice .
            Tab Thironorm 25mcg 
            Tab pause-mf once.
On 23/8/23
           IV Fluids 20 NS
                        10 RL 75ml/hr.
            Inj Neomal 1g intravenous.
            Inj Pantop 40 mg intravenous
            Inj Zofer 4 mg intravenous.
            Tab Dolo 650 mg twice .
            Tab Thironorm 25mcg 
               Tab pause-mf once.

                          
           
      

       
     
       
     
         





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