14year old female with viral pyrexia









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.Venkat Sai PGY1





This is case of 14 year old female came with chief complaints 
1.Fever since 4 days
2.Headache since 4 days

HOPI -

Patient was apparently asympomatic 4days back

Then she developed 

Fever which is of high grade and onset relived with medications,associated with chills and rigors

Headache since 4days  diffuse in region.

No history of cold,cough 

Vomiting since yesterday morning 3-4 episodes 

Abdominal pain since yesterday morning 

PAST HISTORY -

No k/c/o DM/HTN/Epilepsy/CAD/Asthma

TREATMENT HISTORY -
Not significant 

PERSONAL HISTORY-

Diet-Mixed
Appetite-Normal
Sleep-Adequate 
Bowel and bladder-Normal
Micturtion-Normal

No Addictions

FAMILY HISTORY-
Not significant 


GENERAL EXAMINATION -

GENRAL EXAMINATION

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

He is moderately built and nourished 

PALLOR -absent 

ICTERUS -absent 

CYANOSIS -absent 

CLUBBING -absent 

EDEMA -absent 

LYMPHADENOPATHY -absent 




VITALS 

TEMP-96f

PR-92bpm

RR -18 cpm

BP-120/80

Spo2-98


SYSTEMIC EXAMINATION 

CVS-S1S2 heard 

CNS-Higher mental functions intact 

PA-Soft and non tender 

RS- BAE+


DIAGNOSIS 

Viral pyrexia with Thrombocytopenia Dengue NS1 +


INVESTIGATIONS-


13/9/22

Dengue NS 1 +















Treatment-

1.IVF NS and  RL  @75ml/hr

2. INJ PAN 40mg IV/OD

3.INJ ZOFER 4mg/IV/TID

4.INJ NEOMOL 1gm/IV/SOS

5.TAB PCM 650mg PO/QID

6.INJ TRAMASIL 100mg/IV/SOS






 

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