Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.
A 18year old male patient came to the opd with chief complaints of fever since 2days and headache, giddiness on standing since 1day.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2days then he had fever which was intermittent ,relieved on medication,it was associated with chills,rigor.
Patient does not have cough,cold, burning micturition.
Headache was associated with photophobia,nausea and giddiness only on standing
HISTORY OF PAST ILLNESS:
Patient is not a known case of diabetes, asthama, hypertension, epilepsy
PERSONAL HISTORY:
Diet: mixed
Appetite:normal
Bowel and bladder movements:regular
Sleep: adequate
No addictions
FAMILY HISTORY:Not relevant
GENERAL EXAMINATION:
Patient was concious cooperative coherent and well oriented to time place and person.
No pallor,no cyanosis,no icterus,no clubbing
no lymphadenopathy .
Vitals:
Built: average
Temperature:afebrile
Bp:110/80mm/hg
Respiratory rate:16cpm
Pulse rate:84bpm
SYSTEMIC EXAMINATION:
Abdomen:
Shape-scaphoid,no tenderness,no palpable masses,no swellings,no bruit,no hernia
orifices
CVS examination:
S1&S2 heard,no cardiac murmurs.
CNS:
Concious
Speech:normal
Gait:normal
No neck stiffness
Sensory,motor systems are normal
INVESTIGATIONS:
Provisional diagnosis: viral pyrexia with thrombocytopenia
Dengue ns1positive
TREATMENT:Doxy 100mgPO/BD
T.Dolo 650mg PO/TID
IVF NS AND RL 100ml/hr
Inj optineuron 1amp in 100mlNS/OD over 30mins
SVP.CREMAFFIN plus 10ml PO/HS
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