Gm case presentation 2




 This is online elog book to discuss for patients deidentified health data shared after taking her/guardians signed informed consent

Here we discuss our individual patient 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. 

A 40 yr old female came to the casualty with the chief complaint of fever which is intermittent , dry cough and headache since 5 days . 

HOSTORY OF PRESENT ILLNESS : 

pt was apparently assymptomatic 10 days back then she developed fever and went to nearby hospital ,  given medication for which the fever is decreased . 

 After 5 days again she developed same symptoms . Then she came to our hospital. 

Sob during cough . patient daily routine she wakes up at 6am in the morning and have tea at 6.30 and house hold works breakfast around 8 she usually eat rice and go to farm for working have lunch at 1o clock and 7 she will have her dinner and at 8.30 go to sleep 

Past history

No diabetes ,no hypertension

She had hysterectomy 10 years back

Personal history

Patient mixed diet , normal bowel and bladder movement 

Adequate sleep

Family history

No relevant family history

Treatment history

Not allergic to know drugs

General examination

Patient is coherent coperative 

No icterus no cynosis no clubbing no lymphednopathy no oedema feet 

Vitals 

Temp 

BP 

Respiratory rate

Inspection

Cardio vascular system 

Chest wall is bilaterally symmetrical 

No precordial bulgeno visible pulsations

Engorged veins , scars, sinuses

Palpation

JVP normal

S1&S2 heard

Respiratory system

Bilateral airway+

Position of trachea is central

No added sounds

Central nervous system

Patient is conscious

Speech is normal

Reflexes are normal

Investigations

Complete blood picture

Hb 11.7

RBC total count 3100

Neutrophils 84

Lymphocyte 10

Eosinophils 3

Monocytes 3 

Basophils 0

Platelet count 2.23

Smear normocytic normochromic blood picture with leukopenia

Serum elctrolytes 

Sodium 138

Potassium4.3

Chloride 96

Blood urea-23

NS1 antigen positive

Random blood sugar- 91

Serum creatinine- 1.2

Liver function test 

Total bilirubin-0.93

Direct bilirubin-0.20

Alkaline phosphate-156

Total protein-6.7

Albumin-3.7

Treatment

Inj pan 40  iv OD

Inj optineuron1 ampule drink plenty of water, tab dolo650 mg,. Inj neomol 1gm iv 

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