A 19 yr old male with fever and bodypains

 This is an E log book to discuss our patient's de-identified health data shared after taking his guardian sign informed consent. Here we discuss our patient's clinical problems through series of inputs from available global online community of experts with an aim to solve the problem with collective current best evidence based inputs. This E log also reflect my patient centered online learning portfolio and your valuable inputs on comment box.


A 19 year old male patient came to OPD with the chief complaint 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 and associated with bodypains. Relieved on medication.

2 days back he was taken to outside hospital, there his platelet count was 129000 cells/mm3, yesterday count was 132000 cells/cumm and today count is 98000cells/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 hypertension,dm, thyroid, epilepsy


PERSONAL HISTORY

Diet: mixed 

Appetite: normal

Sleep: adequate 

Bowel and bladder movements: normal 


GENERAL EXAMINATION 

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

Moderately built and moderately nourished.

No pallor, cyanosis, icterus, lymphadenopathy.

BP - 90/60 mmHg 

Pr -84

RR - 14cpm

Spo2-99 

Temperature -99.5 F 

CVS - S1 S2 +

CNS- - NAD 

RS - BAE +

P/A - soft, non tender 











DIAGNOSIS

Dengue with thrombocytopenia



TREATMENT 

IV fluids NS @100ml/hr 

Tab dolo 650mg po/tid 

INJ pan 40mg iv/od 

INJ neomol iv of temp> 101 f 

INJ Zofer 4mg iv 

BP and temperature monitoring.




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