45 year old Male with dengue

 


This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are 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, and investigations, and come up with a diagnosis and treatment plan.

Pt came to casuality with c/o fever since 4 days 

HOPI:Pt was apparently asymptomatic 4 days back then he had fever which is of high grade continuous with chills and rigor. No SOB, chest pain, cold,cough, sore throat. No palpitations, sweating ,vomitings.h/o 15 episodes of loose stools yesterday, watery consistency,large quantity,yellow Color, non foul smelling,relieved on medication.

No burning micturition

He went to local hospital where he got tested positive for dengue NS1 Ag

Past history:

 n/k/c/o DM,HTN,TB,asthma,CVA,CAD,epilepsy.

Personal history:

Diet: mixed,Appetite: normal

Bowel and bladder:regular 

No known allergies 

Habits: occasional alcohol ( stopped 6 months back)

Family history: not significant 

General examination:

Pt is conscious,coherent, cooperative 

No pallor,cyanosis, clubbing, lymphadenopathy,edema

Bleeding manifestations:red spots over the palate

HESS test:

Vitals:

Temperature:98.4 f

PR:78 bpm

BP:110/70 mmHg 

RR:19 cpm

SpO2:98%

GRBS:116mg/dl

Systemic examination:

CVS:S1,S2 +, no murmurs 

RS:BAE+,NVBS

Abdomen: obese abdominal wall


Soft, non tender

No organomegaly 

Hernial orifices free

CNS: intact

Investigations:


 


Provisional diagnosis:

Dengue NS-1 Ag positive with thrombocytopenia 

Treatment:

1)IV fluids-NS,RL @100 ml/ hr

2)inj.NEOMOL 1 gm/ iv/sos ( if temp >101F)

3)inj.PAN 40 mg iv/od

4)tab.PCM 650 mg po/sos

5)Bp,PR,RR,temp monitoring 2nd hourly

7)report sos if any bleeding manifestations occur 



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