30y/f c/o fever since 4 days( padma)

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 available 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-centered online learning portfolio and your valuable inputs on the comment box is welcome. 

CASE PRESENTATION:

A 30 yr old female who is an housewife came with 

C/O Fever since 4days

C/O body pains since 2days

C/O vomitings since 2days

C/O headache since 2days

Patient was apparently asymptomatic 2 days back then he developed fever 4 days ago at 8:00pm ,which is Gradual in onset, progressive in nature, association with chills and rigors and presented through out the night ,not associated with night sweats,associated with vomiting two episodes (watery in consistency) contained food particles, non-projectile,non- bilious in consistency.C/O body pains diffuse type.

C/o headache (diffuse type) went to RMP his symptoms subsided 

No h/o blurring of vision ,diploma,no h/o head injury .No c/o burning micturtion ,pedal edema,chest  pain, giddiness, syncope, stomach pain, cough, cold.

Pt c/o small vesicles on lips since 3 days associated with fever.

History of past illness:

Not a known case of DM,HTN .Non-alcoholic and non smoker.

Normal appetite, mixed diet, adequate sleep,  regular bowel and bladder movements and no addictions. 

GENERAL EXAMINATION

PATIENT IS CONSCIOUS,COHERENT AND, COOPERATIVE

THERE IS NO PALLOR,ICTERUS,CYANOSIS,CLUBBING OR LYMPHADENOPATHY

VITALS

PR:78BPM

RR:20CPM

BP:110/80MMHG

GRBS:99MG/DL

SpO²- 99% @ room air

CVS: S1,S2 HEARD NO MURMURS

RS: BAE+,NO ADDED SOUNDS

CNS: NAD

P/A: SOFT,NONTENDER ,BOWEL SOUNDS PRESENT

 REFFERED TO DVL:

C/O SMALL VESICLES OVER BOTH THE LIPS SINCE 3 DAYS ASS WITH PAIN

C/O SWELLING OF THE LT EYE (AROUND LOWER ORBITAL AREA)SINCE MORNING.

H/O FLUID FILLED LESION INTIALLY 1 EPISODE

O/E:RUPTURED HEMORRHAGIC VESICLES NOTED ON BOTH UPPER AND LOWER LIP WITH CRUSTING.

DIAGNOSIS:?HERPES SIMPLEX VIRUS INFECTION

TREATMENT:FUDIC CREAM L/A B/D 1WEEK

INVESTIGATIONS:

RBS:145mg/dl

FBS:70mg/dl

HbA1c:6.5%

Serology: Negative

Blood for M.P. strip test:Negative

Blood grouping: A positive 

 Day2 

Day3

Day4

          Ecg:

Ultrasound:

Diagnisis: 

NS1 POSITIVE DENGUE FEVER

?HERPES SIMPLEX VIRUS INFECTION

Treatment:

DAY 1,2

1. Ivf -Ns,Rl @ 100ml/ hr

2.T.Dolo 650/Po/qid/sos

3.B.P, PR, SPO2 monitoring - 4th hourly

4.temp charting hourly

5.check for bleeding manifestations

6.encourage oral fluids

7.Inj.Neomol 100ml / Iv/  sos

8.Inj. ZOFER - 4mg -IV (sos)

9. Inj . PAN- 40 mg -Iv OD BBF

Day3

1. Ivf -Ns,Rl @ 100ml/ hr

2.T.Dolo 650/Po/qid/sos

3. Inj.Neomol 100ml / Iv/  sos

4.Inj. ZOFER - 4mg -IV (sos)

5. Inj . PAN- 40 mg -Iv OD BBF

6.Fudic cream L/A on lips BD

7.B.P, PR, SPO2 monitoring - 4th hourly

8.temp charting hourly

9.check for bleeding manifestations

10.encourage oral fluids