A 19 y/o make with fever and body pain

 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"


A 19yr old male patient came to the opd with chief complaints of fever Since 1 week.


HOPI:-

Patient was Apparently asymptomatic 1 week back then he developed fever with chills which is high grade ,sudden in onset & associated with body pains .Relieved on medication.

2 days back he was taken to outside hospital there his platelet count was 1,29,000 cells/cumm, yesterday they were 1,32,000cells/cumm.Today they were 98,000cells/ cumm.

No h/o Loose stools, vomitings,

No h/o Hematuria, dark stools.

No h/o pain abdomen,giddiness.


PAST HISTORY:-

Not a k/c/o HTN,DM, Thyroid, Epilepsy.


PERSONAL HISTORY:-

diet- mixed

Appetite- normal

Sleep- adequate

Bowel and bladder movement- normal


GENERAL EXAMINATION:-

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

Moderately built & moderately nourished.

No pallor,Icterus,cyanosis, lymphadenopathy, clubbing.

BP -90/60mmhg

PR -84

RR -14cpm

Spo2 -99

Temp:-99.5 F

CVS- S1 S2 +

CNS- NAD

R/S - BAE +

P/A - soft,nontender .


PROVISIONAL DIAGNOSIS:-

DENGUE( NS1 +, IgM+) WITH THROMBOCYTOPENIA.















TREATMENT:-

1) Iv fluids NS @ 100ml/hr

2) Tab DOLO 650 mg Po/TID

3) INJ PAN 40 mg IV/OD

4) INJ NEOMOL IV/ SOS( IF TEMP >101 F

5) INJ ZOFER 4mg IV/SOS

6) BP AND TEMP MONITERING

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