43 year old male with fever




This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians 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 Elog also reflects my patient centered 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.



A 43 year old male from nalgonda came with chief complaints of fever since 4 days
Generalized body pains and cough since 3 days 
Diffuse pain Abdomen since 3 days
HOPI
Fever is of high grade intermittent type relieved on medication 
Cough is of non productive constant throughout the day
Pain Abdomen is diffuse crampy type relieved mildly on lying down
No history of vomiting loosestools
No history of SOB,PND
Went to hospital outside with platelets count of 60000
HRCT with left upper lobe posterior segment consolidation  and was referred to here



PAST HISTORY:
No H/o similar complaints in the past

Not a known case of Hypertension ,TB,Bronchial Asthma,thyroid, CAD.


TREATMENT HISTORY
Not on any medication


SURGICAL HISTORY:
NO H/O any surgeries in the past


 PERSONAL HISTORY:

Diet: Mixed
Appetite: Normal
Sleep:Adequate
Bowel and bladder movements: Regular
Allergies:No
Addictions:No


FAMILY HISTORY:

No H/o Similar complaints in the family
General examination 
Patient is conscious coherent and coperative well oriented to time place and person 
Vitals 
Bp110/90mmhg
Pulse rate 80bpm
Respiratory rate 20 permin




CVS EXAMINATION:
Cardiac sounds S1 S2 heard
No murmers  heard 


 RESPIRATORY SYSTEM 
Normal vesicular breath sounds heard
Trachea: central
No wheeze

 

ABDOMEN EXAMINATION:

Shape of abdomen: scaphoid
No tenderness 
No palpable mass
Liver not palpable

CNS EXAMINATION 
Conscious ,alert
No motor  deficit
No neck stiffness 
No signs of meningeal irritation 

Provisional diagnosis 
Dengue NS1 positive
With thrombocytopenia 
Left posterior upper lobe consolidation 



ECG


Rx 1.IV fluids NS RL @ 100ml /hr
2.Inj Panton 40mgIv/ Od
3.Inj Augmentin 1.2 gm iv/Tid
4.TabAzee 500mg OD
5.Tab DOlO 650 mg OD
6.Inj.Optineuron 1amp in 100mlNs ivOD
7.Inj Neomol 1gm Iv/sos
8.monitor Vitals
9.Syrp Benadryl 10ml/po/TID

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