25yr male with 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 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. 

This E-log book also reflects my patient centered online learning portfolio and your valuable inputs on the comment box.

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever.


PRESENTING COMPLAINTS:
C/O fever since 5days
Cold since 3days


HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 5days back and he developed fever, high grade, intermittent type, releives on taking medication 
Associated with cold since 2days.
Associated with epigastric pain since 2days
Associated with body pains since 1day.
No H/O cough, headache, vomitings, burning micturation.


HISTORY OF PAST ILLNESS:
Not k/c/o DM, HTN, TB, Epilepsy, CAD, Asthma 


PERSONAL HISTORY:
Diet- Mixed
Appetite- Decreased 
Sleep- Adequate 
Bowel and bladder movements- Regular 
Addictions:
Alcohol-drinks occasionally 
Tobacco- no

No known allergies 

FAMILY HISTORY:
No significant family history.


GENERAL EXAMINATION:
. The patient is conscious,  coherent, cooperative 
. Well nourished and well built 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, Pedal edema.

Vitals:
Temperature- 99F
BP: 120/80 mmhg
Pulse rate: 78 bpm 
Respiratory rate: 16cpm 
SpO2: 98%
GRBS: 108 mg/dl@ admission 

Per Abdomen:
Inspection:- no scars seen.
Palpation:- tenderness in epigastric region.
Percussion:- No free fluid.
Auscultation:- Bowel sounds heard.


SYSTEMIC EXAMINATION:

CVS:

S1 S2 heard 

No cardiac Murmurs

Respiratory system :

No dyspnea 

No wheeze

Trachea position -Central 

Breath sounds -vesicular 

CNS:

No focal and neurological deficits
HMF -Normal
Pupils- Bilateral PSNL

                      Upper limb                        Lower limb


               Right             Left                  Right          Left


Tone:      Normal        Normal            Normal      Normal


Power:           5/5           5/5                   5/5              5/5


Reflexes:         Right             Left


Biceps              +                    +


Triceps            +                     +


Supinator         +                    +


Knee                +                   +


Ankle               +                  +


Plantar         Flexion        Flexion


LAB INVESTIGATIONS:







Peripheral smear:


PROVISIONAL DIAGNOSIS:

Dengue Fever (NS1 positive)


TREATMENT:

IV fluids (NS,RL @100ml/hr)

INJ. NEOMOL 1g IV/SOS

Tab. DOLO 650mg PO/TID

Tab. PAN 40mg PO/OD






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