A 29yr female, with complaints of generalized body pains, difficulty in breathing, headache, abdominal discomfort,vomiting and with thrombocytopenia..

This is an online E log book to discuss our patients deidentified health data shared after taking his/her/guardians signed informed consent.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients 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.

Here is a case I have seen:

Unit 4 Admission

Interns
A.Amrutha
K.Sowmya
Supriya Reddy
Mohitha
Sanjay

Dr.Durga Krishna pgy1
Dr.Ajith pgy2
Dr.Laxma pgy3
Dr.Manasa pgy3
Dr.vijayalakshmi assistant professor(1st on call)

A 29yr female, asha worker by occupation was apparently normal 10 days back and got vaccinated for covid 19 on 19/1/21 and felt generalized weakness for 2 days following which she developed fever  for about 3 days, which was not associated with chills and rigors, intermittent and relieved with medication and patient went to local hospital after 2 days for generalized weakness and got tested positive for NS 1 Dengue where her platelet count was 1,15000 ,
after 2 days they went to the hospital to know platelet count which showed 26,000  and referred to kims for further treatment.. 
Patient also complaints of generalized body pains since 1 week
headache since 1 week which is diffuse not associated with nausea..
There is abdominal discomfort since 1 week
C/o difficulty in breathing which is of grade 2 since 3 days..
H/o vomiting 3 episodes non projectile,non bilious,non blood stained, contained what ever she consumed
H/o 3 episodes of semiformed stools yesterday..
No H/O DM,HTN,TB, ASTHMA, EPILEPSY..

Family history:No significant family history..
Personal History:

Appetite-decreased
Diet-Mixed
Bowel and bladder movements-Regular
No addictions
 
Menstrual history
Age of menarche-13yrs
Regular cycles' 3/28days
No dysmenorrhoea
Not associated with clots
Hysterectomy done 4 years back (Fibroids)

General examination:
Pt is conscious, coherent, co-operative, moderately built and moderately nourished..
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal Oedema..
No Rash , Bleeding gums, Malena..

Vitals
Temperature-Afebrile
BP-90/60mmHg
PR-90/min
RR-.18cpm
Spo2-98% at room air

Systemic Examination :

CVS
S1S2 present
No murmurs

Respiratory system
Normal vesicular breath sounds present
Bilateral air entry present
 
GIT
Inspection :
Abdomen-Mild distension present
No visible pulsations, engorged veins, swellings

Palpation:
Mild diffuse tenderness present in all areas..

Auscultation
Bowel sounds present

Percussion
Normal

CNS
No focal neurological deficit present..

Investigations :
Hb-15.1
TLC-8,000
Platelet-20,000
PCV-43.6
Blood grouping and typing - A positive
Urea -20
Creatine-1
Na+ -139
K+ : 3.4
Cl : 107
 
On 29/1/21
On 28/1/21
USG Abdomen :

ECG :

2D ECHO

29/1/21
Post torniquet test
BT came out to be 3 min 


Provisional Diagnosis
DENGUE FEVER (NS1+) at outside lab
With Thrombocytopenia with Polyserositis

Treatment
IVF-NS @100ml per hour
Inj ZOFER 4mg IV/BD
inj PANTOP 40 mg IV/OD
Inj OPTINEURON 1amp in 100 ml NS/IV/OD
Watch for postural hypotension 
Watch for any bleeding manifestations..

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