VIRAL PYREXIA,THROMBOCYTOPENIA
This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's 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 E-blog also reflects my patient's centred 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.
CHIEF COMPLAINTS:
Patient complains Of fever since 1 week,vomitings since 5 days ,dry cough since 2 days and pain in abdomen since 2 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 7 days back then he had complaints Of fever and chills intermittent evening rise in temperature
He also has complaints of vomitings after the food he ate and he has cough since 2 days and
HISTORY OF PAST ILLNESS:
Patient has a history of thyroid, diabetes mellitus and epilepsy.
PERSONAL HISTORY:
Not married ,student
Appetite is normal,bowel movements are regular, no known allergies
addiction: teetotaler
FAMILY HISTORY: NO SIGNIFICANT FAMILY HISTORY
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative
No pallor icterus cyanosis lymphadenopathy edema clubbing
SYSTEMIC EXAMINATION:
NO THRILLS
S1 S2 POSITIVE
NO CARDIAC MURMURS
RESPIRATORY SYSTEM: NO DYSPNOEA ,WHEEZE
VITALS:
TEMP: 98.2°F
Pulse rate: 96/min
Bp : 110/70mmHg
SpO2: 98
GRBS :84 mg/dl
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS: THROMBOCYTOPENIA, FEVER
FINAL DIAGNOSIS: VIRAL PYREXIA,THROMBOCYTOPENIA
DENGUE NS1 POSITIVE
TREATMENT PLAN:
INJ NEOMOL 1Gm if Temp is above 101°F
INJ ZOFER 4mg IV SOS
INJ PAN 40 MG IV OD
TAB DOLO 650 MG PO BD
INJ MONOCEF 1GM IV BD
TAB DOXY 100G PO BD
