Case history- 11

 This is an online E- log book to discuss our patient's de- identified health data shared informed 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 patient's 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 13 year old male patient came to the  OPD with chief complaints of fever associated with chills , vomitings, loose stools and giddiness since 4 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 4 days  back  and then he noticed fever associated with chills, vomitings of food contents 2- 3 episodes/ day and giddiness since 4 days.

4 days back he noticed loose stools of 5 episodes.

 No history of burning micturition.

PAST HISTORY:

No history of diabetes, hypertension, CAD, asthma, TB, epilepsy, thyroid disorders. 

No history of any surgeries in the past. 

No hematuria, malena, bleeding gums, hematemesis. 

PERSONAL HISTORY:

Appetite: normal 

Diet: mixed 

Sleep: adequate 

Bowel and bladder movements: regular 

Micturition: normal 

Addictions: no

FAMILY HISTORY:

There is no history of similar complaints in the family.

TREATMENT HISTORY:

Patient had not undergone any treatment prior. He is not allergic to any known drugs. 

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative and well oriented to time, place and person. 

There is no signs of pallor,icterus, cyanosis, clubbing, lymphadenopathy and edema.




VITALS:

Temperature: 98.2 °F

Blood pressure: 80/60 mm Hg

Pulse rate:  68 beats / min


SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

No thrills 

S1 and S2 sounds are heard 

No cardiac murmurs

RESPIRATORY SYSTEM:

Dyspnoea- no

No wheezing sounds 

Position of trachea- central 

Breath sounds- vesicular 

ABDOMEN:

Shape of abdomen- scaphoid 

Tenderness- no 

Palpable mass- no 

Hernial orifices- normal 

Free fluid- no 

Bruits- no 

Liver - not palpable

Spleen- not palpable

Bowel sounds- yes 

CENTRAL NERVOUS SYSTEM:

Level of consciousness: conscious 

Speech: normal 

Signs of meningeal irritation

           Neck stiffness- no 

Cranial nerves- normal 

Motor system- normal 

Sensory system- normal 

INVESTIGATIONS:

                  HEMOGRAM



                           ECG



DIAGNOSIS:
Dengue fever with thrombocytopenia 

TREATMENT:

1. Inj. PANTOP IV 40mg OD

2. Inj. ZOFER 4mg IV BD

3.Tab. DOLO 650mg SOS 

4. ORS sachets in 1 litre water 200ml after each stool

5. Tab. SPOROLAC - DS 1 tab. BD

6  Syp. POTCHLOR 10 ml in 1 glass water BD

7. Plenty of oral fluids





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