17 Y/O WITH FEVER

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment plan.

 

A 17 year old female who is a resident of Miryalguda, student by occupation came to the opd with the 

CHIEF COMPLAINTS :

• fever since 15 days
• headache since 15 days
• joint pains,muscle pains since 15 days
• cough since 15 days
• giddiness since 2 days

HISTORY OF PRESENTING ILLNESS : 

                          Patient was apparently asymptomatic 15 days ago,then she developed high grade fever (102-103F) which is abrupt onset, continuous and associated with chills,headache with no aggravating factors and was relieved temporarily on taking paracetamol.

no history of abdominal pain,swelling

no history of epistaxis, bleeding gums, blood in stools

PAST HISTORY:

no history of diabetes, hypertension, asthma, epilepsy, tb, thyroid disorders

PERSONAL HISTORY:

She wakes up at 7AM in the morning, brushes her teeth and does her daily activities. She used to go to her intermediate college which she got passed out recently, now she is staying at her home 

She takes mixed diet, normal appetite, sleep was normal but since 15 days she was unable to sleep properly because of body pains, bowel movements were irregular(4times weekly) and bladder movements were regular and consumes toddy occasionally.

FAMILY AND SOCIOECONOMIC HISTORY:

history of fever to her sister and niece.

patient belongs to lower middle class, lives in a kutcha house, family of 5, uses tap water as drinking water no water purification methods are used.

House is surrounded by municipal drainage and numerous breeding places were noted.

TREATMENT HISTORY: n/a

ALLERGIC HISTORY: n/a 

GENERAL EXAMINATION:

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

moderately built and moderately nourished.

     Pallor - Absent

     Icterus - Absent

     Clubbing - Absent

     Cyanosis - Absent

     Lymphadenopathy -Absent

     Dehydration- Present 

 

 

 

VITALS:

      PR - 94beats per min

      RR - 42 cycles per min

      BP -  100/70 mm of Hg

      Temp -99.8 F

      SPO2- 99%

 

SYSTEMIC EXAMINATION:

 

CVS: S1 S2 heard, no murmurs heard

RESPIRATORY SYSTEM:  normal vesicular breath sounds + bilateral air entry+

PER ABDOMEN: scaphoid shape, no tenderness, palpable masses, normal hernial orifices, liver and spleen are not palpable

CNS: no focal neurological defecits

 

INVESTIGATIONS

     

DIAGNOSIS:

DENGUE HEMORRHAGIC FEVER