23 Y/O WITH FEVER AND THROMBOCYTOPENIA

 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 23 year old male who is a computer operator by occupation, resident of Nakrekal came to the OPD with

CHIEF COMPLAINTS :

• fever since 7 days
• pain abdomen since 7 days
  

HISTORY OF PRESENTING ILLNESS : 

                          Patient was apparently asymptomatic 7 days ago,then he developed fever (99F) which is abrupt onset, continuous and not associated with chills,headache with no aggravating factors and was relieved temporarily on taking paracetamol and he developed abdominal pain which was sudden onset, gradually progressive, not localized, but pain is more around umbilical area and right hypochondrium area 

h/o nausea and vomitings-2 episodes on day2 of fever

h/o rash over inner thighs, non-pruritic in nature, not associated with any pain, no aggravating and relieving factors

h/o redness of the eyes yesterday

PAST HISTORY:

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

h/o polio since birth

PERSONAL HISTORY:

He takes mixed diet, decreased appetite, sleep was normal, bowel movements were irregular(4times weekly),constipation since 4 days and bladder movements were regular, no addictions.

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 - 90beats per min

      RR - 22 cycles per min

      BP -  110/70 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, tenderness+, palpable masses, normal hernial orifices, liver and spleen are  palpable

CNS: no focal neurological deficits

 

INVESTIGATIONS:

 

PROVISIONAL DIAGNOSIS: DENGUE HEMORRHAGIC FEVER

 

TREATMENT: