55 year old female with chief Complaints of fever

 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 a series of inputs available global online community of experts with the aim to solve the patient’s clinical problems with the collective current best evidence based inputs. This E log reflects my patient centred online learning portfolio and your valuable inputs in the comments section.


A 55 yr old female who is a home maker came to opd with c/o fever since 4 days. 


Patient was apparently asymptomatic 4 days back then she developed fever which was high grade and continuous type, didn't releive on medication.


 H/o 1 episode of vomiting 4 days back contents being food particles, non bilious, non projectile.  


H/o giddiness & fall 3 days ago.  


No c/o SOB, pedal edema 


No c/o melena, hemetemesis 


K/c/o HTN since 2 yrs on medication ( Tab,. ATENELOL 50mg PO / OD ) 


She went to a local doctor 3 yrs back i/v/o generalised itching for which she was prescribed Tab. Prednisolone 10 mg PO/OD & was using it since then 


Not k/c/o DM, asthma, thyroid disorders , epilepsy 




O/E : 


Pt is c/c/c 


Vitals : 


Temp: 99.4 f


HR: 78 bpm


RR : 20cpm


BP : 110/80 mm hg


Spo2: 99 @ RA






SYSTEMIC EXAMINATION : 




CVS : S1 S2 + . 


RS : BAE + NVBS + 


PA: soft, Non tender   


CNS : NAD 



DIAGNOSIS : DENGUE ( NS 1 POSITIVE)  



TREATMENT :


IVF - NS, RL @ 100 ml / hr


Inj. PANTOP 40 mg IV / OD 


W/F bleeding, postural hypotension 


Inj. OPTINEURON 1 amp in 100ml NS IV/ OD 


INJ. NEOMOL 1 gm IV /SOS ( if temp > 101 F)  


Tab. DOLO 650 mg PO/ TID


 

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