GM: ELOG 45 yr old female

GM : ELOG  45 year old female 

NOTE

This is an ongoing case and will be updated .
This e log is made under the guidance of Dr. TEJASWINI 
The reference link (if any) will be mentioned at the bottom.

Date of admission: 31/08/21

HISTORY OF PRESENT ILLNESS- 
  • A 45 yr old female pt came with chief complaints of fever with chills since 3 days
  • Hopi - pt was apparently asymptomatic 3days back then she developed high grade fever associated with chills ,rigors
  • No c/o of cough, cold, 
  • No c/o of chest pain , palpitations, syncopal attacks
  • No c/o of sob , orthopnea ,pd
  • Nausea present 
  • no vomiting 
  • loose stools
  • No c/o of abdominal distention 
  • C/o of , burning micturition, decreased urine output 

PAST HISTORY
  • No h/o HTN,, CVA, CAD,TB, epilepsy.
  • K/c/o dm since 2 yrs on regular medication 

PERSONAL HISTROY
  • Decreased appetite
  • Bowel and bladder movements are regular
  • Non alcoholic , non smoker 
  • The patient is conscious coherent and cooperative
  • Moderately built and moderately nourished. 

VITALS
  • PR:80bpm
  • BP:110/80 mmHg
  • RR:16cpm
  • Spo2:99% at RA
  • GRBS: 560mg%

PHYSICAL EXAMINATION
  • Shape of abdomen: scaphoid
  • Abdominal tenderness is present in epigastric region 
  • Hernial orifices- normal
  • No free fluid
  • Liver and spleen - not palpable
  • Bowel sounds are present

CVS: 
s1 ,s2 heard 

RS:
 vesicular breath sounds are heard 

CNS: normal 

Post lunch blood sugar


Glycated hemoglobin 



X-RAY



HEMOGRAM




Provisional diagnosis:
Viral pyrexia with thrombocytopenia (?  Dengue)

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