50 years male with Fever and SOB
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT .
50 year old male Farmer by occupation came with chief complaints of
Fever since 11days
Lethargy since 5 days
Blood in saliva since 4 days and
SOB since 3 days.
History of presenting illness:
Patient was apparently alright 11days back then he had low grade fever , intermittent , relieved on taking medication . Not associated with chills and rigors and doing his routine works , from 5 days as patient was lethargic and taken to local hospital found out to be Dengue NS 1 reactive and
platelet count
44,000———>22,000—(SDP transfusion)—>33,000
From 4 days patient notices blood in saliva and while during coughing.
Severe cough from 4days.
Black coloured stools from 3 days.
patient is having Grade 2 --- Grade 4 ( NYHA ).
PAST HISTORY :
Not known case of DM2 , Hypertension , Asthma , TB , Epilepsy .
PERSONAL HISTORY :
Diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movements- regular
Addiction : alcohol intake daily 30 ml whisky
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
No Pallor
No icterus,
No cyanosis,
No clubbing,
No koilonychia,
No lymphadenopathy,
No edema
VITALS:
Temp.- Afebrile
PR- 55 bpm
RR- 36 cpm
BP- 130/70 mmHg
SpO2- 92% at RA , 98% on 4 lit O2
GRBS- 137 mg/dl
SYSTEMIC EXAMINATION:
CVS: S1S2 heard, no murmurs
RS: BAE+ ,Tachypnoea,fine inspiratory crept’s present in (RT>LF) infrascapular areas and infraaxillary area
P/A: Soft, Non-tender
CNS: NAD
Provisional diagnosis:
Severe ARDS with Dengue NS 1 reactive with Thrombocytopenia.
Treatment:
1. IVF NS , RL @ 50 ml/hr
2. W/F Bleeding manifestation
3. Strict I/O charting
4. BP monitoring
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