38 YEAR OLD FEMALE WITH FEVER AND THROMBOCYTOPENIA

Kausalya Varma, Intern 

This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan. 



AN 38 YEAR OLD FEMALE BROUGHT TO THE HOSPITAL WITH FEVER, CHILLS AND BODY PAINS FOR 1 WEEK 


CASE:


CHIEF COMPLAINTS: 


A 38 year old female patient came with the complaints of fever, chills, and body pains for the past one week. 
She is a resident of Mothkur, and a daily wage worker until 18 years ago, when she stopped working to work at home.

HISTORY OF PRESENT ILLNESS: 

- Patient was apparently asymptomatic 1 week back when she developed fever and chills which was insidious in onset, continuous, low grade, decreasing on taking medications, had no aggravating factors and was slightly increased toward the evening.
- She also had complaints of headache and body pains for the past one week. Headache is localised in the frontal region. Not associated with nausea, vomiting, blurring of vision, photophobia. 
- No peteciae and purpura seen and no other bleeding manifestations were observed.
- Patient had no burning micturution, occasionally had difficulty in passing stools and passed blood. 
- No tingling sensation and numbness in the legs, no giddiness, no cough, no cold and no pain or abdominal tenderness is observed.


PAST HISTORY-

- No similar episodes in the past. 
- Patient is a known case of HIV since 2005, and is on dolutegravir, lamivudine and tenofovir disoproxil fumarate tablets (50mg+300mg+300mg) for the past 12 years.
- Patient is not a known case of diabetes, hypertension, tuberculosis, epilepsy, asthma, thyroid and CAD. 
- H/O tubectomy 16 years ago.

PERSONAL HISTORY- 

Diet: Mixed 
Appetite: Decreased for the past 1 week 
Sleep: Decreased for the past 1 week 
Bowel and Bladder: Regular, occasionally (every 5-6 months) she has blood in stools 
No allergies
Takes alcohol/toddy occasionally (only on festivals) 

FAMILY HISTORY- 

No similar history in family. 

GENERAL EXAMINATION- 

Patient is examined in a well lit room after taking informed consent. 
Patient is conscious, coherent and cooperative. 
She is moderately built and moderately nourished. 

Pallor: Present 
Icterus: Absent 
Cyanosis: Absent 
Clubbing: Absent 
Generalized Lymphadenopathy: Absent 
Edema: Absent
Dehydration: Mild 

VITALS
Blood Pressure: 110/70 mmHg
Respiratory Rate: 19 cycles per minute
Pulse: 108 bpm
GRBS- 107mg%

Temperature: Afebrile


SYSTEMIC EXAMINATION: 

RESPIRATORY SYSTEM-  


Inspection-

Chest is bilaterally symmetrical

The trachea is positioned centrally

Apical impulse is not appreciated 

Chest moves normally with respiration

No dilated veins, scars or sinuses are seen


Palpation- 

Trachea is felt in the midline 

Chest moves equally on both sides 

Apical impulse is felt in the fifth intercostal space 

Tactile vocal fremitus- appreciated 


Percussion-

The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.

They are all resonant.


Auscultation-

Normal vesicular breath sounds are heard

No adventitious sounds heard



CARDIOVASCULAR SYSTEM- 


Inspection- 

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse or pulsations cannot be appreciated 


Palpation-

Apical impulse is felt in the fifth intercostal space, 2 cm away from the midclavicular line

No parasternal heave or thrills are felt 


Percussion- 

Right and left borders of the heart are percussed 


Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 


ABDOMEN EXAMINATION

INSPECTION:

Shape – scaphoid
Flanks – free
Umbilicus –central in position , inverted.
All quadrants of abdomen are moving equally with respiration.
No dilated veins, hernial orifices, sinuses
No visible pulsations.

PALPATION:
No local rise of temperature and tenderness
All inspectory findings are confirmed.
No guarding, rigidity
Deep palpation- no organomegaly.

PERCUSSION:
There is no fluid thrill , shifting dullness.
Percussion over abdomen- tympanic note heard.

AUSCULTATION:
Bowel sounds are heard.


CENTRAL NERVOUS SYSTEM-


HIGHER MENTAL FUNCTIONS:

Patient is Conscious, well oriented to time, place and person.


All cranial nerves - Intact


Motor system

                              Right.                  Left


BULK 

Upper limbs.        N.                         N

Lower limbs         N.                         N


TONE

 Upper limbs.       N.                        N

 Lower limbs.      N.                        N


POWER

 Upper limbs.      5/5.                    5/5

 Lower limbs      5/5.                    5/5



Superficial reflexes and deep reflexes are present, normal

Gait- Could not elicit, the patient was not able to get off the bed

No involuntary movements


Sensory system- All sensations (pain, touch, temperature, position, vibration sense) are well appreciated



INVESTIGATIONS : 

23/12/22

HEMOGRAM

Hemoglobin: 11.6
TLC: 5300
Platelet: 1.50 (previous day- outside report said 9800)
MCV: 79.2
MCH: 25.4
PCV: 36.2
RBC COUNT: 4.57

ELECTROLYTES
Na: 136
Cl: 101
K: 3.6

RBS- 80
HbA1C- 6.1


RENAL FUNCTION TESTS
Urea: 30
Creatinine: 0.6

LIVER FUNCTION TESTS
Total Bilirubin: 2.48
Direct Bilirubin: 1.5
SGOT: 147
ALT: 129
ALP: 112
Total Protein: 6.7
Albumin: 3.6
A/G: 1.16


ECG- 


2D ECHO-



USG ABDOMEN-





PROVISIONAL DIAGNOSIS-


Viral pyrexia under evaluation with HIV positive, with thrombocytopenia (98,000) 



TREATMENT- 


On 23/12/22

On admission, patient was given IV neomol 

On 24/12/22

1) IVF- 10NS, 10RL @75ml/hr
2) Plenty of oral fluids 
3) Tab Dolo 650mg PO TID
4) Tab Ultracet PO BD
5) Normal oral diet
Continue the normal medication schedule 



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