Case history -5

 27 September, 2021

" This is 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 comment box is welcome. "

A 40 year old female presented to the OPD with chief complaints of fever associated with chills, vomiting, loose stools.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 5 days back then developed high grade fever which is now resolved. Vomitings which were non-bilious with food particles as content. Loose stools 3-4 episodes , black stools and few episodes of red stools.

No history of hematuria

No history of burning micturition 

PAST HISTORY:

No history of diabetes, tuberculosis, HTN, epilepsy , CAD.

PERSONAL HISTORY:

Appetite- normal

Sleep- adequate

Diet- mixed 

Bladder movement- regular

FAMILY HISTORY:

No history of HTN, diabetes, CAD in the family.

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative.

No cyanosis

No clubbing

No lymphadenopathy

No edema

Pallor is seen.

VITALS:

Temperature: afebrile

Pulse rate: 110 beats/min

BP: 110/60 mm Hg

Respiration: 22/min

SYESTEMIC EXAMINATION: 

CVS:

S1 S2 heard.

RESPIRATORY SYSTEM:

Postion of trachea- central

Breath sounds - vesicular

No wheeze

No dyspnea

ABDOMEN:

Shape of abdomen- Scaphoid

No tenderness 

No palpable mass

Hernial orifices- normal

No bruits

CNS:

Level of consciousness -conscious

Speech- normal

No neck stiffness

INVESTIGATIONS:

DIAGNOSIS: 

 Viral pyrexia ( resolved) with thrombocytopenia and bloody diarrhoea.

TREATMENT:

Inj. Piptaz 4.5 gm/IV/QID

Oral fluids~2L

Inj. Tranexa 500mg /IV/SOS

Inj. Vit K 1 amp in 50 ml NS/IV/OD

Inj. PAN 40 mg/IV/OD

Inj. Optineuron 1 amp in 50 ml NS/IV/OD

Egg whites 4 /day.