fever with thrombocytopenia

55yr old female with fever (dengue NS1+) with Thrombocytopenia 

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This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

K.Medha Reddy, intern 

Roll No: 61

I have 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 diagnosis and treatment plan.

CASE:

A 55 yr old female came to the hospital with chief complaints of :

• Fever since 5days

• Headache since 5 days  

• Generalised weakness since 5 days

HOPI:

Patient was apparently assymptomatic 5 days ago, then she developed Fever which was high grade, associated with chills, more during nights, not relieved on taking medications and is associated with Generalised body pains

C/O headache since 5days, in frontal region, not relieved on medication.

H/O generalised weakness since 5days

H/O loss of appetite since 1 week.

H/O peri-orbital pain +

Negative history:

No H/O cold and cough

No H/O vomitings, loose stools

No H/O Malena, Hematuria 

PAST HISTORY:

Not a k/c/o DM/HTN/Epilepsy/Asthma/TB/CAD/ CVA/Thyroid disorders 

PERSONAL HISTORY:

Diet : mixed

Appetite : Decreased since 1 week

Sleep : Adequate 

Bowel habits : regular

Bladder habits : regular

FAMILY HISTORY : Insignificant

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative and was examined in a well lit room with informed consent. 

No Pallor, icterus, cyanosis, clubbing, lymphadenopathy, peadal edema.

Mild dehydration+

VITALS:

Temperature : 99F

PR : 76bpm

RR : 16cpm

BP : 100/70 mmHg

SPO2 : 98% on RA

GRBS: 86mg/dl

JVP : not seen

Petechiae seen on lower limbs and in palms

Palatal petechiae seen

SYSTEMIC EXAMINATION:

CVS : 

S1, S2 heard

No added murmurs

CNS : 

Higher and lower motor functions normal

Sensory system is intact

No focal neurologic deficits 

RS : 

Bilateral Air entry present.

NVBS heard

P/A : 

INSPECTION:

Shape: Scaphoid 

Umbilicus is inverted

PALPATION: 

Soft

Tenderness + in Right Hypochondrium and Epigastric region 

Splenomegaly could be felt.

Fluid thrill is ABSENT

PERCUSSION: 

Liver dullness + 

AUSCULTATION: 

Normal bowel sounds heard

DIAGNOSIS:

DENGUE FEVER (NS1+) WITH THROMBOCYTOPENIA 

INVESTIGATIONS:

2D ECHO: 

EF: 64%, NO RWMA, MILD LVH+, IVC SIZE: 0.8CMS, RSVP: 40MMHG, MILD AR+/TR+ WITH PAH, NO MR, NO AS/MS, SCLEROTIC AV, GOOD LV SYSTOLIC FUNCTION, NO DIASTOLIC DYSFUNCTION, NO PE

USG ABDOMEN:

Garde 1 fatty liver, Mild increase in size 

Mild splenomegaly (15cms)

Gall bladder wall edema

No Ascites

Rt. Mild pleural effusion

Hemogram trends:

29/1/23: HB: 9.2, TLC: 1,100 PLT: 60,000

30/1/23: HB: 13.9, TLC: 2,800 PLT: 40,000

31/1/23: HB: 14.2, TLC: 5,700 PLT: 41,000

REPEAT: HB: 12.8, TLC: 4,800 PLT: 70,000

1/2/23: HB: 13.0, TLC: 5,100 PLT: 65,000

2/2/13: HB: 12.6 

TREATMENT: 

IVF NS @ 100ML/HR

INJ. NEOMOL 40MG IV OD BBF

INJ PAN 40MG IV OD BBF

INJ ZOFER 4MG IV SOS

INJ OPTINEURON 1 AMP IN 100ML NS IV OD

TAB DOLO 650MG PO s 

PLENTY OF ORAL FLUIDS