A CASE OF DENGUE

This is an E-log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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 comments in comment box are most welcomed .

I have been given this case, in an attempt to solve and understand the topic of "Patient's clinical data analysis”. This has helped me develop my competency in reading and comprehending clinical data including history taking, clinical findings and investigations. The goal is to come up with a diagnosis and treatment plan.  

PAVITRA BALDAWA  

ROLL NUMBER -104

3rd November 2021

CHIEF COMPLAINS:

A 20 year male patient waiter by occupation and a resident of Nalgonda came to medicine OPD with chief complains of fever since 5 days

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 5 days ago when he developed fever

which was sudden in onset and gradually progressive

Intermittent in nature

Associated with pain abdomen which increases on inspiration and is continuous

PAST HISTORY:

No similar complains in the past

Not a known case of diabetes, hypertension, epilepsy ,tuberculosis ,asthma.

No past surgical and medical history

PERSONAL HISTORY:

Diet- vegetarian

Appetite- normal

Sleep- adequate

Bowel and bladder- regular

Addictions and allergies- none

FAMILY HISTORY:

Insignificant

GENERAL EXAMINATION:

The patient is conscious coherent and cooperative, well orientated to time place and person

He is moderately built and well nourished

Pallor-absent

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Edema-absent

VITALS: 

Pulse:80bpm

Blood pressure:120/80mmhg

Respiratory rate:14cpm

Temperature:99 degree Fahrenheit

SYSTEMIC EXAMINATION:

Cvs- S1 and S2 heard and no murmurs or thrills

Respiratory- normal vesicular breath sounds

Per abdomen- soft and non tender

Cns- higher motor functions normal

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

Dengue with thrombocytopenia

TREATMENT:

Inj. Pantop - 40mg IV OD 

 Inj. Neomol - 100ml IV SOS

Tab. Dolo - 650mg P/O SOS 

Grilinctus syrup - 10ml P/O TID

IV NS 125ml/hr

IV RL 125ml/hr