40 year male with fever
August 28, 2022
This is online E-blog, to discuss our patient de-identified health data shared after taking her 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 the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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 a diagnosis and treatment plan.
Our 40yr old male patient came to the opd with chief complaints of
C/o fever since 4days
Hopi:
Patient was apparently asymptomatic 4days ago later developed fever insidious in onset intermittent not associated with chills and rigors relieved on medication.
No h/o nausea ,vomiting , abdominal pain
No h/o burning micturition
No h/o cold and cough
Patient went to near by hospital there by doing investigations dengue NS1 was positive and platelets were of 35,000 cells/cu mm and patient was referred to our hospital i/v/o platelet transfusion.
Past history:
No similar complaints in the past
Not a k/c/o DM,HTN,TB,CAD, EPILEPSY
Personal history:
Diet mixed
Appetite normal
Sleep adequate
Bowels Regular
Micturition Normal
No addictions
Family history:
Not significant
General examination:
Patient is c/c/c
Temp: 98.6F
Bp: 100/70mmhg
PR: 86bpm
RR: 16cpm
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No edema
Systemic examination:
CVS: S1 S2 sounds heard
RS: BAE+, clear
P/A : soft and non tender
CNS: NAD
USG
Investigations:
RBS:126mg/dl
Blood urea:47 mg/dl
Serum creatinine:1.2mg/dl
Diagnosis:
Dengue with thrombocytopenia
Treatment:
1)IV fluids NS and RL @100ml/hr
2) INJ OPTINEURON 1AMP in 100ml NS
3)INJ NEOMAL 1gm IV /SOS
4)Strict I/O charting
5) Monitor vitals
