A 24 YR OLD MALE WITH H/O FEVER SINCE A WEEK

Meghana 

Roll.no :161 ( 9th semester )

DATE :-14/12/2021

Introduction :

This is 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 comments on comment box are welcome.

A 24 yr old male visits OPD with 

Chief complaints : - 

• Fever since 1 week 
• Giddiness since 3 days & 
• And black colored stools since 2 days 

History of present illness :- 

The patient was apparently asymptomatic 1 week ago , he then developed high grade fever associated with chills during the night time for 2 days , the fever would be moderate during the daytime .

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He visited a local RMP and used medication for 3 days and the fever subsided .

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H/ O giddiness for 3 days and intermittent fever 

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H/ O shortness of breath for 2 days 

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H/ O black coloured stools since 2 days , the patient was admitted to our hospital on 11/12/21                                                                                   

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He developed a rash on his left cheek a day ago 

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No H/O headache , vomitings , loose stools , body pains , burning micturition , cold or cough 

Past Hist0ry :- 

No similar complaints in the past 

No H/ O  HTN, DM , Asthma , TB , Epilepsy 

Personal History :- 

• Diet - mixed 
• Appetite - normal 
• Sleep - adequate 
• Bowel movements - normal , bladder movements - increased micturition
• Addictions - occasionally consumes alcohol 
• No known allergies 

Family history :- 

No significant family history 

GENERAL EXAMINATION :-

Patient was conscious , coherent and cooperative , he was examined in a well lit room after having taken his consent 

• VITALS :- Temperature -98.3 F 
•                   Pulse rate - 98 bpm 
•              Respiratory rate - 20 cpm 
•                 BP -130/80 mm of Hg 
•                 SpO2 - 98 % at RA 

- No signs of pallor , icterus , clubbing , cyanosis , lymphadenopathy or oedema 

SYSTEMIC EXAMINATION :-

CVS :- S1, S2 heard 

           No thrills or murmurs noted 

Respiratory system :- BAE + 

-Normals vesicular breath sounds heard 

-Trachea is central in position 

-No wheezing or dyspnoea present 

Per abdominal examination :- 

- Soft , non tender , no evidence of organomegaly 

- No palpable masses , mild ascites 

- Bowel sounds heard 

CNS examination :-NAD 

Patient's clinical images :- 

Rash on left cheek 

Investigations :- 

X-ray:

ECG :-

USG : 

RBS:

complete urine examination :-

Hemogram :- 

Liver function test : 

Provisional diagnosis :- Dengue fever with thrombocytopenia ( NS1 + ) 

Treatment :- 

 (11/12/2021) 

1) IVF NS,RL,DNS- @100 ml/hr.

2) Inj pantop 40 mg IV OD

3) W/F postural hypotension, bleeding manifestations

4) tab doxycycline 100 mg po BD

5) Inj optineuron 1 amp IV OD in 100 ml DNS

6) BP,PR 4th hourly

7)  Temp charting 4th hourly

8)  GRBS 12th hourly.

 UPDATE (12/12/2021):-

• IVF NS,RL,DNS- @100 ml/hr.
•  Inj pantop 40 mg IV OD 
• doxycycline 100 mg po BD
•  Inj optineuron 1 amp IV OD in 100 ml DNS
•  BP,PR 4th hourly
•  Temp charting 4th hourly
•  GRBS 12th hourly.

UPDATE ( 13/12/2021):-

• IVF NS,RL,DNS- @100 ml/hr.
•  Inj pantop 40 mg IV OD 
• doxycycline 100 mg po BD
•  Inj optineuron 1 amp IV OD in 100 ml DNS
•  BP,PR 4th hourly
•  Temp charting 4th hourly
•  GRBS 12th hourly.

UPDATE ON 14/03/2021:-

• IVF NS,RL,DNS- @100 ml/hr.
•  Inj pantop 40 mg IV OD 
• doxycycline 100 mg po BD
•  Inj optineuron 1 amp IV OD in 100 ml DNS
•  BP,PR 4th hourly
•  Temp charting 4th hourly
•  GRBS 12th hourly.
• Lulican cream BD 
•