60 yr old female with Fever ,Backache and Generalised weakness since 5 days

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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.

 60 year old female was admitted to opd with chief complaints of

1.Fever since 5 Days

2.Backache since 5 days

3.Generalised weakness since 5 days

HOPI :

Patient was apparently asymptomatic 5 days ago.The she developed high grade fever which was sudden in onset , continuous without diurnal variation and not associated with chills and rigor.

She even complained of backache since 5 days which is insidious in onset , gradually progressive and persistent.

She even complained of generalized weakness since 5 days

Then she went to govt hospital where she was diagnosed with low blood pressure and decreased platelets.

As her condition was not improving she was admitted in our hospital.

Daily routine:

She wakes up at 5 am and does her morning routine and takes tea at 7am and takes her breakfast (rice+ Vegetable curry)at 9 am and then goes for work.she works as labourer in the farm fields.she takes her lunch by 1pm(rice + vegetable curry) and she come home by 5:30 pm and completes her daily chores and eat dinner by 8:30 pm (rice + vegetable curry) and goes to sleep by 9 pm.

Past history:

Not a known case of Diabetes, Hypertension, Asthma ,TB, epilepsy and thyroid disorders.

No history of previous surgeries.

Personal history:

Diet : Mixed

Appetite: decreased

Sleep: disturbed

Bowel and bladder movements : Regular

History of smoking 2 to 3 times a day since 40 yrs

Family history:

No significant family history

General examination:

Patient is conscious coherent and cooperative

Moderately built and nourished 

Well orientated to time place and person

Pallor - absent

Icterus - absent

Cyanosis- absent

Clubbing- absent

Lymphadenopathy - absent

Edema - absent

Vitals:

Temp: afebrile

BP: 80/60 mm hg

Pulse: 90 bpm

RR: 30cpm

Systemic examination:

Abdominal examination:

Inspection:

On inspection abdomen is slightly distended, no flank fullness, umbilicus is centre and slit like.No scars seen.No engorged veins 

Palpation:

All inspectory findings are confirmed.

Tenderness is seen on the right hypochondrium region.

Percussion:

No significant findings

Auscultation:

Bowel sounds heard

Clinical pictures:

CVS: S1 S2 heard

Respiratory system : Bilateral air entry present Normal vesicular breath sounds

CNS: No focal neurological deficits

Investigations:

                           

                            USG

Provisional diagnosis:

Dengue fever with thrombocytopenia , Acute kidney injury , Acute liver injury