A 27-year-old male patient with complaints of fever for 4 days

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








This E blog also reflects my patient-centered online learning portfolio and your valuable input in 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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

MED CASE:-

A 27-year-old male patient with complaints of fever for 4 days

COMPLAINTS:- 

complaints of Fever for 5 days.

The patient was apparently asymptomatic 5 days 
back, then developed
Fever, high grade, associated with
chills and
rigors, relieved with medication.
- No complaints of Vomiting, bed urine output /burning micturition/ cough/cold /Loose stool.

No complaints of PainAbdomen/Or any bleeding manifestations
i.e., Nohematuria/ Melena or  blood
in stool/Bleeding gums
Petechiae /rash.
No SOB/chest pain/palpitations

0/E :- Petechiae + over the palatal mucosa


HESS TEST :- 
Negative 




Not a k/c/o HTN, DM, CVA, CAD, TB, Asthma, or thyroid disorders. 

Allergic history:-

No history of any kind of allergies to food/drugs

Family history:- 

No significant family history 
 

GENERAL EXAMINATION:- 


THE PATIENT IS CONSCIOUS COHERENT AND COOPERATIVE 
NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ODEMA ; LYMPHADENOPATHY 









TEMPERATURE:- AFEBRILE
PR:81bpm
BP:120/80mmhg
RR:18cpm

SYSTEMATIC EXAMINATIONS:-

CVS:S1 S2+,NO MURMURS
CNS: NAD
RS:BAE+ ; NVBS 
P/A:SOFT ; NON TENDER ; NO ORGANOMEGALY 

PROVISIONAL DIAGNOSIS:- 
? Viral hemorrhagic fever 
? Dengue 

INVESTIGATIONS:- 


NS 1 - POSITIVE 

HAEMOGLOBIN
15.4
TOTAL COUNT
4,000
NEUTROPHILS
60
LYMPHOCYTES
32
EOSINOPHILS
01
MONOCYTES
07
BASOPHILS
00
POV
43.8
MCV
# 81.9
MCH
28.8
MCHC
# 35.2
RDW-CV
12.7
RDW-SD
38.5
RBC COUNT
5.35
PLATELET COUNT 36.000

Total Bilirubin 0.91 
Direct Bilirubin 0.18 
SGOT(AST) 19
SGPT(ALT) 57
ALKALINE PHOSPHATE  133 


TP - 7.2

Alb - 4.4 



APTT  - 32 Sec


BT - 2Min 30Sec

Ст - 4 Min 30Sec


PT - 16 sec 

INR - 1.11


RBS-112mg/dl


B. Urea - 15 mg/ dl

S- Creat -0.9 mg/dl

Na - 137 mEq/L

K - 3.7 mEq/L

C1 - 102 mEq/L


USG:- NO SONOLOGICAL ABNORMALITY DETECTED.

DIAGNOSIS:- 

DENGUE (NS1 positive) 


Day 1:- 



31/08/23
ward: AMC
DOA: 30/8/23

DR. NIKITHA (SR)
DR. NARSIMHA (PGY2)
DR. VIVEK (PGY1)

S - C/o High grade fever since 5 days 
associated with chills and rigors. 
no h/o vomitings, pain abdomen, bed urine output, burning micturition, cough, cold, Loose stools.
no C/o bleeding gums, hematuria, SOB, chest pain, palpitations. 

O -  viral pyrexia  (Dengue NS1 positive)

A: On examination 
Patient is conscious coherent and cooperative. 
No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.
Petechial rash over the palatal mucosa.

Vitals:
Temp: 100.8 F
PR: 95 BPM
BP:130/70 MM/HG
RR: 18 CPM
CVS: S1 ,S2 heard
RS:B/L AE present , NVBS +. No added sounds
P/A:Soft, non tender, no organomegaly.
No rigidity,Guarding.
CNS: NAD

P:
1) IV FLUIDS NS @100ml/hr 
2) Inj. Neomol  1gm / IV/SOS
3) Tab. Dolo 650 mg PO/ SOS


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