VIRAL PYREXIA WITH THROMBOCYTOPENIA, DENGUE

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 competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.


• CHIEF COMPLAINTS
A 16 year old male came to the casualty with complaints of

fever since 4 days which is  intermittent,low grade and not associated with chills and relieved on medication

Pain abdomen since 4 days which is generalised, intermittent and squeezing type

Vomitings 2 episodes non bilious,non projectile associated with nausea


• HISTORY OF PRESENT ILLNESS
Patient was asymptomatic 4 days back and then he developed fever which is intermittent, low grade ,not associated with chills and relieved on medication( paracetamol TID).
He also had pain abdomen which is generalised, intermittent ,squeezing type
He also complains of Nausea and vomiting 2 episodes (non bilious and non projectile).

There is no H/o rashes, burning micturition,hematuria,hematemesis,melena



• PAST HISTORY
Not a known case of DM,HTN,TB,CVA,CAD,Asthma,
Epilepsy.



• PERSONAL HISTORY
Appetite-normal
Diet-mixed
Bowel and bladder movements-regular
Addictions-none
Sleep- regular



• FAMILY HISTORY
No relevant family history



• GENERAL EXAMINATION
On Examination patient is conscious, coherent and cooperative
Moderately built and moderately Nourished
No pallor
No icterus
No clubbing
No cyanosis
No lymphadenopathy
No edema


VITALS
Temp-98.2 degrees F
PR-67 bpm
RR-20 cpm
BP-110/70 mm Hg
Spo2-100%



• SYSTEMIC EXAMINATION
CVS: S1 and S2 heard
RS: BAE+; NVBS+
P/A: Soft,non tender
CNS: NFD


• INVESTIGATIONS










• TREATMENT
IVF:NS,RL 75 ML/HR
INJ.PAN 40 MG IV/OD
INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD
INJ.ZOFER 4 MG IV/BD
BP,PR,SPO2 Monitoring 4th hourly
strict I/O charting

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