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


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