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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.
Name :- Kattekola Sathwik
Roll no 75
Case Report
An 18 yr old Female student hailing from Rural Nalgonda has presented to the casuality with C/O Fever since 3 days - high grade , C/O cold Since 3 days and C/O Nausea since 3 days
Patient was apparently normal 3 days ago then she developed Fever which was Insidious in Onset , High grade, Continuous associated with Chills and Rigors , no diurnal variation
History of Cold since 3 days
Patient also reports that she Has headache and Body pains. No C/O Cough, Loose stools
Patient reports to have nausea but had No episodes of Vomiting Till date
Patient also gives History of Burning Micturition since 3 days.
Patient also reports to have Pain abdomen Since 2days Intermittenr, no aggrevating or relieving factors
Associated Comorbidities
K/C/O Hypothyroidism Since 2 yrs Initially used T.Thyronorm 100 mcg currently using T.Thyronorm 50 mcg
Past History
Not a known case of HTN, DM, Asthma, TB Epilepsy ,CAD ,CVA
Personal History
She Reports to have decreased appetite since 2 months
Diet is Vegetarian
Bowel and Bladder habits arw regular
No Addictions
No Allergies
GENERAL PHYSICAL EXAMINATION :-
Patient is C/C/C
No pallor , Icterus, Cyanosis, Clubbing, Lymphadenopathy, Pedal Edema
At the time of admission
Temperature :- 97.8 F
PR:- 92 BPM
RR:- 18 CPM
BP :- 90/60 MMHG
SPO2 :- 99 AT ROOM AIR
GRBS :- 142 MG%
Oral cavity :- petechiae on Palate
CVS :- S1S2 + NO MURMURS
RS :- BAE + NVBS HEARD
PA :- SOFT NON TENDER
CNS :- NO FOCAL NEUROLOGICAL DEFECT
Diagnosis :- PYREXIA UNDER EVALUATION WITH K/C/O HYPOTHYROIDISM
INVESTIGATIONS
Serial hemograms
1. Iv fluids
2. Inj. PAN 40 MG IV OD
3. INJ . ZOFER 4 mg iv BD
4. Inj. NEOMOL 1G 1V SOS
5. TAB. PCM 650 mg PO TID
6. TAB. THYRONORM 50 MCG PO OD
7.INJ. OPTINEURON in 100 mL NS IV BD
Soap notes
2/3/2023
S
FEVER Subsided
O
Pt is C/C/C
Temp :- 98.5F
PR:- 86 bpm
RR:-15cpm
BP:-100/60 mmHg
CVS :-s1s2 present no murmurs
RS:-BAE+NVBS
PA:- Soft
CNS :- HMF intact NFND
A
DENGUE (NS1 POSITIVE) WITH PANCYTOPENIA WITH HYPOTHYROIDISM
P
1. INJ.PAN 40 MG IV OD
2. INJ ZOFER 4MG IV BD
3. INJ .NEOMOL 1G IV SO [IF TEMP >101F]
4.INJ.OPTINEURON 1 AMP IN 100ML NS IV BD
5.TAB.PCM 650 MG PO SOS
6. TAB.THYRONORM 50MCG PO OD
3/3/2023
S
FEVER Spikes at 8pm on 2/3/23, 2am and 9 am on 3/3/23
O
Pt is C/C/C
Temp :- 99.6F
PR:- 95 bpm
RR:-16cpm
BP:-100/60 mmHg
CVS :-s1s2 present no murmurs
RS:-BAE+NVBS
CNS :- HMF intact NFND
A
DENGUE (NS1 POSITIVE) WITH PANCYTOPENIA WITH HYPOTHYROIDISM WITH ANEMIA (?IDA)
P
1. INJ.PAN 40 MG IV OD
2. INJ ZOFER 4MG IV BD
3. INJ .NEOMOL 1G IV SO [IF TEMP >101F]
4.INJ.OPTINEURON 1 AMP IN 100ML NS IV BD
5.TAB.PCM 650 MG PO SOS
6. TAB.THYRONORM 50MCG PO OD
4/3/23
S
FEVER Spikes at 10pm on 3/3/23, 12Am,2Am and 4Am on 4/3/23
C/o Pain Abdomen with Nausea
C/0 increased mestrual bleeding (associated with clots)
O
Pt is C/C/C
Temp :- 98.6 F
PR:- 94bpm
RR:-18cpm
BP:-supine-100/80mmHg
Standing-90/70mm hg
CVS :-s1s2 present
no murmurs
RS:-BAE+NVBS
CNS :- HMF intact
NFND
A
DENGUE (NS1 POSITIVE) WITH PANCYTOPENIA WITH HYPOTHYROIDISM WITH ANEMIA (?IDA)
P
1.IV FLUIDS
1. INJ.PAN 40 MG IV OD
2. INJ ZOFER 4MG IV BD
3. INJ .NEOMOL 1G IV SO [IF TEMP >101F]
4.INJ.OPTINEURON 1 AMP IN 100ML NS IV BD
5.INJ BUSCOPAN IV/BD
6.TAB.PCM 650 MG PO SOS
7.TAB.THYRONORM 50MCG PO /OD
8.INJ TRANEXA 500 mg IV/BD
5/3/2023
S
FEVER Spikes at 10pm on 4/3/23, 2Am and 4Am on 5/3/23
C/o pain abdomen and nausea decreased
C/0 increased menstrual bleeding (associated with clots) decreased
O
Pt is C/C/C
Temp :- 97.8F
PR:- 96bpm
RR:-20cpm
BP:-supine-100/70mmHg
Standing-90/70mm hg
CVS :-s1s2 present
no murmurs
RS:-BAE+NVBS
CNS :- HMF intact
NFND
A
DENGUE (NS1 POSITIVE) WITH PANCYTOPENIA WITH HYPOTHYROIDISM WITH ANEMIA (?IDA)
1 SDP Transfusion Done on 4/3/23 9pm
P
1.IV FLUIDS
1. INJ.PAN 40 MG IV OD
2. INJ ZOFER 4MG IV SOS
3. INJ .NEOMOL 1G IV SO [IF TEMP >101F]
4.INJ.OPTINEURON 1 AMP IN 100ML NS IV BD
5.INJ BUSCOPAN IV/SOS
6.TAB.PCM 650 MG PO TID
7.TAB.THYRONORM 50MCG PO /OD
8.INJ TRANEXA 500 mg IV/SOS
6/3/2023
S
NO FEVER SPIKES
C/o pain abdomen and nausea decreased
C/0 increased menstrual bleeding (associated with clots) decreased
O
Pt is C/C/C
Temp :- 97.8F
PR:- 88bpm
RR:-18cpm
BP:-110/70mmhg
CVS :-s1s2 present
no murmurs
RS:-BAE+NVBS
CNS :- HMF intact
NFND
A
DENGUE (NS1 POSITIVE) WITH PANCYTOPENIA WITH HYPOTHYROIDISM WITH ANEMIA (?IDA)
P
1. PLENTY OF ORAL FLUIDS 2.TAB.THYRONORM 50MCG PO/OD 3.TAB.PCM 650 MG PO SOS
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