16/M came with c/o FEVER

 This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect6current best evidence based input
This Elog also reflects my patient centered online learning portfolio.
Your valuable inputs on 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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever


Under the guidance of 

Dr. Vinay PGY3

Dr.Pavani PGY1




This is a case of 16 year old student who presented to the op with the chief complaints of 

1.Fever since 7 days which is of high grade continuous not associated with chills and rigors, relieved 2 days back 

It is not associated with cold cough burning micturition sob chest pain orthopnea PND 

2.loose stools since 6 days 4-5 times a day 

Watery in consistency,non foul smelling,not associated with blood

3. Vomitings 6days back of 2 episodes 

Non bilious, non foul smelling, particles non blood stained ,watery 

No complaints of hematuria, petechiae on soft palate, melena

Yesterday 3 episodes 

Today as of 8 am 1 episode 

ORTHOSTATIC HYPOTENSION present 


PAST HISTORY 

No history of CAD/CVA/Epilepsy/Asthma/TB


PERSONAL HISTORY

Diet- non veg 

APETITE - normal 

Bowel and bladder movements - regular 

Sleep - adequate 

Addictions - none 


FAMILY HISTORY 

Not significant 


GENERAL EXAMINATION 

The patient is coherent conscious cooperative and well oriented to time place and person 

He is moderately built and nourished 

Pallor -absent 

Icterus -absent 

Cyanosis- absent 

Edema -absent 

Lymphadenopathy - absent 


VITALS 

TEMP 97.4

BP110/80

PR82

RR bae+

GRBS 100


SYSTEMIC EXAMINATION 




CVS- S1 S2 heard 

Cns- higher motor functions intact 

Pa- soft and non tender 

Rs- normal vesicular breath sounds heard 


Diagnosis 

Viral pyrexia with thrombocytopenia 

Investigations 

23/8/2022

Hemogram 1@ 8.52 am



Hemogram-2


Hemogram-3@8.19 PM










Treatment 

Ivf 2 NS and 2 RL @150ml/hr

Inj zoffer 4mg iv/sos

BP/PR/ RR/spo2 monitoring 







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