A 35 year Old Female Who is a Known case of Polio Comes to Casualty with Fever and Cough

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I have 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.

ANKUR KUMAR

ROLL NO. 14

October 20, 2021

A 35 year Old female came to Casualty on 17/10/21 with chief complaints of 

Fever since one week 

Cough since one week

Vomitings since 4 days

HISTORY

The patient is a 35 year old unmarried female born out of non-consanguineous marriage first in the birth order. When she was 6 years old, she suffered from high grade fever and also associated weakness in left upper limb and lower limb. She was diagnosed as a case of Polio.

On advise of a neighbour who also suffered from polio, She had undergone a surgery in Thirupathi which was unsuccessful. 

History of Presenting Illness

She was Suffering from Fever since 1 week which is Sudden in onset, high grade and continuous and doesn't subside on medication.

Fever associated with Cough which is non productive.

Patient had 3-4 episodes of Vomitings.

PAST HISTORY

No similar complaint in past.

No h/o: 

Diabetes Mellitus, 

Hypertension , 

Epilepsy,

Tuberculosis.

FAMILY HISTORY

No significant family history.

PERSONAL HISTORY

Diet : mixed 

Appetite : Decreased 

Sleep : Disturbed dur to Coughing.

Bowel and Bladder : Regular 

No know drug and food allergy 

No addictions 

GENERAL EXAMINATION

Patient was conscious , coherent and  well oriented to time , place and person

 

Moderately built and well nourished 

No pallor , icterus , cyanosis , clubbing , lymphadenopathy , edema 

VITALS AT THE TIME OF ADMISSION

Temp- 98.1F

PR- 95BPM

RR- 20/MIN

 

BP- 100/80MMHG 

SPO2- 99% 

SYSTEMIC EXAMINATION

RESPIRATORY - Bilateral inspiratory crepts in all lung fields.

CVS - S1 S2 heard 

No added murmures 

ABDOMEN - Soft and non tender 

Bowel sounds heard 

CNS - 

Higher functions intact

 

Motor System -  Tone increased in upper left limb and lower limb .

Power     Upperlimb.      Lowerlimb 

Rt                   5                      5

Lt                   4                      4

Reflexes            Right     Left 

BICEPS                2+      -

TRICEPS              2+      - 

SUPINATOR        2+      -

KNEE                   3+     3+

ANKLE                  +      +

INVESTIGATIONS

Hemogram , RFT , LFT , NSI ANTIGEN , SEROLOGY , CHEST XRAY , ECG 

NS 1 Antigen positive

PROVISIONAL DIAGNOSIS

 Dengue (NS1 Antigen positive) with Thrombocytopenia

TREATMENT :

On 18/10/2021