60yr/f with back ache & fever since 10 days

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CBBLE UDHC Similar case



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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 a diagnosis and treatment plan 

60 year old female came with the complaints of back pain since 20 days C/O fever since 10 days C/O burning micturition  since  10 days 

patient was apparently asymptomatic  20 days ago then she developed back pain which is dragging type,  aggravated on sitting and relieved with meditation and rest 
C/O  fever since 10 days high grade , intermittent , relieved with medication H/O burning micturition  since 10 days
 H/O  vomiting 2 to 3 episode in 10 days,  non bilious,  non projectile food as content 
H/O  of headache  since 2 days 
NO H/O of blurring of vision 
NO H/O  cough,  cold,  loose stools, joint pains. 
 
 

N/k/c/o DM, HTN, BA,TB, EPILEPSY, CVA, THYROID DISORDERS 


Temp : 97.8 f
PR : 86 bpm 
BP  : 110/70 mm hg
RR  : 18 cpm
SPO2 : 98 % @RA

Cvs : s1 s 2+ 
Rs : BAE + 
CNS : NAD
P/A : soft & non tender 





INVESTIGATIONS : 
 
DENGUE NS1 : Positive 

HB: 13.1
TLC: 5700
N/L/E/M/B : 35/58/0/7/0
PLT : 48, 000

sr cr : 0.6
Na+/k+/cl- : 137/3.4/98
Urea :  20

TB : 0.81
DB : 0.27
AST: 337
ALT: 157
ALP: 465
TP: 5.7
ALB: 1.21



USG abdomen : minimal ascitis, gall bladder edema 


DIAGNOSIS : Dengue fever with thrombocytopenia 

TREATMENT : 
1)IVF NS , RL @100ml/hr
2) INJ. PAN 40 mg/iv/OD
3) INJ.ZOFER 4 mg /i.v/ TID
4)INJ.OPTINEURON 1amp in 100ml NS i.v/OD
5)TAB.DOLO 650 mg /po/TID
6)INJ. NEOMOL 1gm /iv/ sos
7)T.ULTRACET 1/2 tab sos
8) SYP. POTCHLOR 10 ml in 1 glass of water.

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