19M with fever

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"


Cheif Complaints :
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
Addictions:-
Patient doesn’t smoke
Non alcoholic 

Drug history:-
No relevent drug history

GENERAL EXAMINATION:-

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

Moderately built & moderately nourished.

No pallor,
Icterus,
cyanosis,
Generalised lymphadenopathy,
 clubbing.

Vitals:-
BP -90/60mmhg

PR -84

RR -14cpm

Spo2 -99

Temp:-99.5 F

Systemic examinations:-

CVS- S1 S2 +

CNS- NAD

R/S - BAE +
Chest - bilaterally symmetrical 
No drooping of shoulders.
Trachea - central in position 

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

Comments

Post a Comment

Popular posts from this blog

35 yr female with shortness of breath

Image
A 35 year old female from marapaka, came to casualty with c/o shortness of breath since 20 days.  History of present illness :- Pt was apparently asymptomatic, 2 months back then she developed breathlessness which is insiduous in onset since 20 days which aggrevated on performing physical work and was relieved on rest. Then she  visited a local hospital in miryalaguda, on evaluation she had low hemoglobin count and 2 blood transfusions were done and was given medicines for a week. After using these medicines for one week she developed bilateral pedal edema (pitting type). So she visited a hospital in guntur. As there are no aarogyasri services in guntur she came back to nalgonda regarding the same issue. She had one more blood transfusion in Nalgonda hospital. Later she developed breathlessness and visited our hospital. She was on medication and her breathlessness subsided after 3 days of admission. She had 5 blood transfusions here and was on dialysis(10). Pedal edema did not subside
Read more

19 year old male with joint pains

Image
 A 19 year old male student came with a chief complaint of joint pains since four days. HISTORY OF PRESENT ILLNESS:-  Patient came to the causality with joint pains since 16/3/2022  Patient is a known case of sickle cell Anemia and Beta thalassemia. He had severe joint pains in the past also since 4 years . He was given IV fluids and antibiotics for the pain. HISTORY OF PAST ILLNESS:- In 2008 patient had yellow discoloration of eyes and visited our hospital and was given iron supplements  In 2012 patient was adviced for HPLC Patient HbF: 27.7% HbAo: 5.4% HbA2: 4.7 HbS : 61.3 - diagnosed with sickle cell Anemia and Beta thalassemia. Patient was adviced to take folic acid 5mg everyday. In 2018 patient had joint pains 1 episode and visited hospital and was given IV fluids and the pain subsided after 4-5 days. In 2019 again the patient had severe joint pains 1 episode and was given IV fluids. In 2020 and 2021 also patient had 1 episode of joint pains each year . In 2022 he had 4 episodes o
Read more

67 year old female with shortness of breath

Image
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. CHIEF COMPLAINT A 67 year old female from nadikuda, farmer by occupation has come to the OPD with chief complaints of shortness of breath, pedal edema and decreased urine output since 3 months HISTORY OF PRESENT ILLNESS  Patient was apparently asymptomatic 1 year back when she noticed decreased urine output and was diagnosed with heart failure and started taking medication for the same. 3 months back she noticed
Read more