60y/F with fever since 1 day

20thThis 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  60 yrs female ,farmer by occupation came with complains of
C/o fever since 1day
C/o headache and body pains since 1day
C/o 1 episode of vomiting (containing food particles).
Patient was apparently asymptomatic 1 day back then she developed fever(sudden in onset,gradually progressive associated with chills and rigors ) more during nights not associated with night sweats.
C/o headache (diffuse type not associated with diplopia) 
c/o dyspepsia since 1 yrs
C/o body pain (diffuse type) which aggrevated on work and relieved on lying down. 
No c/o chest pain, burning micturation, palpitations, SOB, pedal edema ,at loss, giddiness, cough ,cold.

K/c/o grade 2 cystocele with SDI(2019)

Not a k/c/o HTN, DM, asthama,thyroid,TB

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

 General examination:

Patient is conscious,coherent and cooperative, well oriented to time, place and person.
Well build and nourished 
No pallor,  icterus, cynosis, clubbing,  lyphaedenopathy, edema
Temp- afebrile 
Bp-100/80mmhg 
PR-114bpm
GRBS-108mg/dl
SpO² - 99% @  room air

Systemic examination:- 

CVS- S1S2 HEARD, normal, no murmurs
CNS- NO abnormality detected
RS - BAE+, NVBS+,NO added sounds
P/A: soft, non tender, bowel sounds +

INVESTIGATIONS:
DAY1

Hemogram:
Hb=12.3gm%
TLC=7,500
N/L=85/10
PC=193

DENGUE :-
Ns1Ag : POSITIVE
IgG:Negative 
IgM:Negative 
                            RFT:

Chest X ray

                                  ECG:
               Ultrasound abdomen:
Day2
 
 2D ECHO

Day4
                     Hemogram
                     CUE:
Day7
                  Hemogram 
HBA1C: 6.9%
FBS : 134mg/dl
 
                        Daily chart:
Diagnosis:
NS1 Ag positive dengue fever with
K/C/O Grade 2 Cystocele with
Denovo DM Type 2
Treatment :
Day 1
1) IVF 2NS,RL,DNS 100-125ml/hr
2) PCM 500mg QID
3) Inj.NEOMOL 1gm IV SOS
4) monitoring BP, PR ,SpO²,Temp hourly
5) I/O Charting
Day2-3
1) IVF 2NS,RL,DNS 100-125ml/hr
2) PCM 500mg QID
3) Inj.NEOMOL 1gm IV SOS
4) monitoring BP, PR ,SpO²,Temp hourly
5)I/O Charting
6) Encourag oral fluids
Day4-6
1) IVF 2NS,RL,DNS 100-125ml/hr
2) PCM 500mg QID
3) Inj.NEOMOL 1gm IV SOS
4) inj.Pantop 40mg IV BBF
5) monitoring BP, PR ,SpO²,Temp hourly
6)I/O Charting
7) Encourag oral fluids

Day7
1) IVF 2NS,RL,DNS 100-125ml/hr
2) PCM 500mg QID
3) Inj.NEOMOL 1gm IV SOS
4) Inj.MONOCEF 1gm IV BD
5) T.Doxycycline 100mg PO OD
6) Inj.Pantop 40 mg IV BBF
7) Monitoring BP, PR ,SpO²,Temp hourly
8) I/O Charting
9) Encourag oral fluids

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