Case 8 2nd nov

 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 patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome."

A 36 year old male patient,farmer by occupation came to the opd with chief complaint of body pains,loss of appetite, cough, fever and diffuse pain abdomen 
 No history of vomiting, loose stool and SOB

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 4 days back.

Then he developed fever and cough . Fever

Fever was associated with chills 

No vomiting, no loose stool, no SOB

PAST MEDICAL HISTORY:-

Not known case of hypertension , asthma, epilepsy, TB,  diabetis. 

PERSONAL HISTORY:

Diet -mixed  

Appetite : normal

Bowel & Bladder movements: regular

Sleep :adequate

Addictions: Alcoholic  occassionally

FAMILY HISTORY:-

no history of  similar complaints in the family.

TREATMENT HISTORY:-

no history of drug allergies.

GENERAL EXAMINATION:-

 patient was conscious,coherent and cooperative

No pallor

no clubbing

No cyanosis, 

No icterus, 

No generalised lymphadenopathy

VITALS-

temperature - 37degree Celsius

Pulse - 80 bpm

Respiratory rate -20/min

Bp-110/90

SYSTEMIC EXAMINATION -

CVS-inspection

Chest wall is bilaterally symmetrical.

No precardial bulge

No visible pulsations, engorged veins, scars and sinuses

PALPATION

Jvp is normal

AUSCULTATION -

S1 ans s2 heard

RESPIRATORY SYSTEM:

Bilateral air entry +(BAE) 

Normal vesicular breath sounds heard( NVBS).

PER ABDOMEN:-

abdomen is not tender and soft

CNS:-

patient is concious

Speech is present and normal.



PROVISIONAL DIAGNOSIS:- dengue fever

Investigations:-

Hb- 15.8gm/dl

Tc-5, 200 cells/mm3

Pcv 44.6 vol%

Mcv 83.4

Mchc 35.4%

PLT 62,000/mm3

Smear-normocytic normochromic

RFT:-

urea 3L

S. Creatinine 1.0

S. Na+ 135

S. K+ 3.5

Cl- 97


Treatment:-

IV FLUIDS NS

                    RL 25ml / hr

Inj AUGMFMTIN 1.2gm IV

Inj PAN 40 mg IV/OD

Tab AZEE 500mg OD

Tab DOLO 65mg QID

Inj OPTINEURON 1p in 100ml IV / OD

Inn NEOMOL 1gm IV/ sos

Daily pcv monitory

W/F bleeding manifestations

Syp ASCORYL 10ml TID

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