35yr old female know case of polio comes with fever and cough

 This is an online E log book to discuss our patient's   


de-identified health data shared after taking 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 patient's clinical problems with collective current best evidence based inputs.


MUSKAAN GOYAL ,


ROLL NO. 92

October 18, 2021

A 35yr old female presented to the causality  at 6 O clock  on 17 /10/2021 with chief compliants of 

FEVER SINCE 4 DAYS 

COUGH SINCE 4 DAYS 

VOMITING SINCE MORNING 

HISTORY :

35year old unmarried female born out of non consanguineous marriage first in birth order .she studied till 1st standard . At age of 6 , one day she suddenly developed fever high grade nd associated left upper limb and lower limb weakness and she was diagnosed to have polio. She was taken to thirupati for some surgery which was advised by one of her neighbour who aslo suffered from polio. She underwent surgery in thirupati which was unsuccessful

She was on oral medication for 2yrs , over time she regained power in Lt.UL and LL . She does her own household chores  and takes care of herself nd her family members .

Since then patient had no major illness.

She has now been experiencing fever since 4 days which is sudden in onset ,high grade  nd continuos nd doesn't relief on medication and there is no diurnal variations .

Fever is associated with cough which is non productive.

Pt also had 3 episodes of vomiting which was non bilious , non blood stained and non projectile since morning .vomiting was mainly after a episode of cough.

PAST HISTORY:

No similar complaint in past.

No h/o DM , HTN , CAD , EPILEPSY , TB


FAMILY HISTORY :

No significant family history.

PERSONAL HISTORY:

Diet : mixed 

Appetite : decreased since she was having fever 

Sleep : disturbed due to cough 

Bowel and bladder : regular 

No know drug and food allergy 

No addictions 

GENERAL EXAMINATION: 

Pt was concious , coherent and we'll Oriented to time , place and person 

Moderately built and we'll 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% at room air 

GRBS - 138mg%

SYSTEMIC EXAMINATION :

Respiratory:

Bilateral inspiratory crepts in all lung fields.

Cvs: 

S1 S2 heard 

No added murmures 

Per 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 

B               2+      -

T               2+      - 

S                  2+      -

K                  3+     3+

A                 +      +

P Flexion bilaterally 

INVESTIGATIONS :

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







NSI ANTIGEN POSITIVE 

PROVISIONAL DIAGNOSIS: 

DENGUE (NS1 ANTIGEN POSITIVE) WITH THROMBOCYTOPENIA.

TREATMENT:
 

On 18/10/2021



On 19/10/2021:

On 20/10/2021



On 21/10/2021




On 22/10/2021



On 23/10/2021

































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