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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan
CONSENT AND DEIDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever
Under the guidance of
Dr. Vinay PGY3
Dr.Pavani PGY1
This is a case of 24 year old primi , homemaker presented to Casuality with the chief complaints of
1) Suprapubic pain 4 days back
2)Fever since 4 days
3) Vomitings since 2 days
The patient is apparently asymptotic 4 days back. She developed suprapubic pain which lasted for one day for which she sought for consultation at a local hospital and was diagnosed to be having dengue fever after work up.
fever which is of high grade, intermittent associated with chills and rigors relieving on medication
Vomitings of 2episodes/day immediately after consumption of food containing food particles, non bilious,non projectile, non foul smelling, non blood stained
Burining micturition+
No history of loose stools, bleeding gums, rash, hematuria, malena
PAST HISTORY
She is not a known case of diabetes, hypertension,asthma,cad,epilepsy
PERSONAL HISTORY
Diet-mixed
APETITE -normal
Sleep-adequate
Bowel and bladder movements -normal
Addictions -none
FAMILY HISTORY
not significant
MENSTRUAL HISTORY
Age of menarche -16 years
Cycles- regular 3/28
Pads used per day -3
Bleeding,clotting- absent
GENERAL EXAMINATION
The patient is conscious coherent cooperative well oriented to time place and person
She is moderately built and nourished
Pallor -
Icterus -absent
Cyanosis-absent
Clubbing -absent
Edema -absent
Lymphadenopathy -absent
VITALS
Temp-96f
BP-100/70
Rr-16
Pr-82
Spo2 -99
GRBS -102
SYSTEMIC EXAMINATION
CVS -s1s2 heard
PA-vertical scar of 7-8 cm from xiphisternum to below,hypertrophied scar, non tender
RS-BAE+
CNS- Higher motor functions intact
Diagnosis
Primi with dengue NS1 +
Investigations
Malarial parasite -ve
30/8/2022
USG for antenatal patient
1/9/2022
1/9/22
S:Burning senasation in
oral cavity(mouth)
Fever spike negative
Stools passes negative
O: pt is consious,
Coherent,cooperative
Temp- 97.9f
BP- 90/60mmhg
PR-92/min
CVS- s1,s2heard
RS- BAE+,NVBS
CNS -NAD
GRBS- @8am- 81mg/dl
A:Viral pyrexia with DENGUE NS1
postive
PRIMI GRAVIDA with28weeks GA
MILD ANEMIA
P: plan for treatment
1.Inj cefotaxim 1gm/IV/BD
2.Inj Fluids 10NS @75ml/hr
10RS
3.Inj Zofer 4mg/IV/BD
4.Inj Pan 40mg/IV/OD
5.Tab PCM 650mg/PO/TID
6.Inj Neomol 1gm/IV/SOS
7.Strict I/O charting
8.BP/PR/RR/ SPO2 charting
2/9/22 , 8am
S: Burning micturtion
Pain in suprapubic region
Fever spike negative
O: pt is consious,
Coherent,cooperative
Temp-98.2f
BP-80/60 mmHg
PR-92bpm
CVS-S1,S2 +
RS- BAE+
CNS- NAD
GRBS@8am- 79mg/dl
A: Viral pyrexia with dengue NS1 positive
Primigravida with 28weeks GA
Mild anemia
P:Plan of treatment
1.Inj cefotaxim 1gm/IV/BD
2.Inj Fluids 10NS @75ml/hr
10RS
3.Inj Zofer 4mg/IV/BD
4.Inj Pan 40mg/IV/OD
5.Tab PCM 650mg/PO/TID
6.Inj Neomol 1gm/IV/SOS
7.Strict I/O charting
8.BP/PR/RR/ SPO2 charting 2nd hourly
3/9/22 ,8:30am
S: Fever spike negative
Burning micturition negative
O: pt is consious,
Coherent,cooperative
Temp- Afebrile to touch
BP- 90/60 mmhg
PR- 84bpm
RR-19cpm
CVS-s1,s2 +
RA- BAE+
CNS- NFVD
A: Viral pyrexia with. thrombocytopenia. dengue NS1 positive
24 year old Primigravida with 28weeks GA
with Mild anemia.
P:Plan of treatment
1.Inj Fluids 10NS @75ml/hr
10RS
2.Inj Zofer 4mg/IV/BD
3.Inj Pan 40mg/IV/OD
4.Tab PCM 650mg/PO/TID
5.Inj Neomol 1gm/IV/SOS
6.Strict I/O charting
7.BP/PR/RR/ SPO2 charting 2nd hourly
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