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 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 comment box is welcome

 21 October 2021

A 35 yr old woman presented to the causality with 

  Fever Since 1 week 

Cough Since 1 week

Vomiting Since morning 

History Of Present Illness

Patient is apparently asymptomatic since 1 week back and then developed low grade fever ,intermittent ,No diurnal variations along with non productive cough since 3 days 

3 episodes of non projectile , non bilious, non blood stained vomiting since morning 

Past History 

She was a 35 yr old unmarried woman born out of a non consanguineous  marriage, first in birth order studied till 1st  grade, one day she suddenly developed sudden onset of upper and lower limb and she was diagnosed with polio,She was taken to Thirupathi hospital for Surgery 

She was on oral medication for 2 yrs ,overtime she regained power in Left upper limb and Left Lower limb.She does her own chores in the house and takes care of herself.

 

Personal History 

Diet:Mixed 

Appetite :Normal

Sleep:Adequate 

Bowel and Bladder moments:Regular

Family History 

Not significant 

General Examination 

 No Pallor 

No Cyanosis 

No Clubbing 

No Icterus

No Lymphadenopathy 

Vitals

Temp: 98.1F

PR : 95/min

RR :20/min

BP :100/80

Systemic Examination 

CVS

S1 and S2 heard

P/A

Soft non tender

CNS

Tone increased in left upper limb and lower limb

Lungs

Bilateral Inspiratory crepts  in all Lung fields.

Provisional Diagnosis  

Dengue fever with Thrombocytopenia (NS1 Antigen positive)

 

Treatment 

IV 75 ml/hr

Plenty of oral fluids 

INJ Pantop 40 mg/IV/OD

INJ Zofer 4 mg /IV/OD

Tab Dolo 650mg

IV Neomal if temp>101F