Case 3

A 45 year old woman with complaints of fever, shortness of breath and weakness.

Hi, I am R. Ramya Keerthana , 3rd semester medical student.This is an online elog book to discuss our patient's health data after taking his/her consent.This also reflects my patient centered online learning portfolio.

Case Scenario
A 45 year old woman came to the hospital on 20th August with complaints of fever, shortness of breath and weakness.

Chief complaints
- fever with chills since 10 days, intermittent and relieved on medication
- shortness of breath since 5 days
- weakness since 10 days
- generalized body pains since 10 days
- headache since 10 days
- loss of appetite since 3 days
- abdomen pain

History of present illness
Patient was asymptomatic 10 days back, then she developed fever with chills which is intermittent and relieved on medication. 

She also had headache and generalised body pains since 10 days.

She developed shortness of breath on exertion 5 days ago which was progressive.

No history of chest pain, palpitations, syncope and edema.

History of past illness
Not a known case of diabetes mellitus, hypertension, asthma, CAD, tuberculosis and cancer.

Treatment History
She had uterine swelling more than a year ago for which she was suggested hysterectomy, but the swelling went away after medication and hysterectomy was not done.

Personal History
Married
Occupation: farmer
Appetite: lost
Mixed diet
Regular bowels
Normal micturition
No allergies 
No addictions

Family History
Not significant

Physical examination
No pallor, icterus cyanosis, clubbing, lymphadenopathy, edema, malnutrition and dehydration.

Vitals
Pulse rate: 110 bpm
Respiratory rate: 34 bpm
BP: 110/80 mm Hg
SPO2: 96% at RA
RBS: 122 mg/dl
Temperature: 98° F

Systemic examination
CVS
No thrills
No cardiac murmurs
S1 S2 heard

Respiratory system
No dsypnoea and wheezing
Vesicular breathing sounds
Trachea in central position

Abdomen
Scaphoid shape
No tenderness, palpable masses, free fluid, bruits, bowel sounds
Liver and spleen not palpable
Normal hernial orifices

CNS
Conscious, normal speech, no neck stiffness and kerning's sign is negative
Cranial nerves, motor system and sensory system normal
All reflexes normal
Cerebellar coordination normal
Gait is normal

Investigations
Hemogram
Complete Urine Examination
RFT
Blood urea: 28 mg/dl
Serum creatinine: 0.9 mg/dl
Serum sodium: 136 mEq/L
Serum potassium: 4.5 mEq/L

LFT
Total bilirubin: 0.91 mg/dl
Direct bilirubin: 0.19 mg/dl
SGPT: 106 IU/L
SGOT: 122 IU/L
ALP: 341 IU/L
Total protein: 6.7 gm/dl
Albumin: 2.46 gm/dl
A/G ratio: 0.58
Pus cells: 2-4

ECG
Blood typing
1 unit of SDP transfusion done

Chest X -ray
Pleural effusion observed

Tested positive for Dengue Ns1Ag and non- reactive for IgG and IgM on 19th August.

Medication Chart









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