21 year old male

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.

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, investigations, and come up with a diagnosis and treatment plan.

A 21 year old male came to the OPD with complaints of 

fever since one week.

abdominal pain and distention since one week.

loss of appetite since 1 week.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic one week ago then he developed fever which was High grade and intermittent and relieved on medication abdominal pain and distention since 1 week

-no history of vomiting , loose stools

-no history of headache

He got treated in a local hospital for 4 days for fever and he was referred to KIMS Narkatpally as his platelet count was low.

HISTORY OF PAST ILLNESS

Not a known case of Diabetes Mellitus, hypertension , Asthma , Epilepsy , Coronary artery disease , Tuberculosis.

PERSONAL HISTORY

Student by occupation who follows Mixed Diet, loss of appetite, regular bowel and bladder movements, no known  addictions

FAMILY HISTORY:

His mother has Hypertension

GENERAL EXAMINATION

Patient is conscious , coherent and cooperative

Moderate build and not malnutri

His body temperature is 98.4 degree Farenheit

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema

SYSTEMIC EXAMINATION

Cardiovasular system: S1 and S2 are heard, No murmurs

Respiratory system: Bilateral air entry is present , Normal vesicular breath sounds are heard

Per Abdomen examination: soft nontender and bowel sounds present

INVESTIGATIONS:

HEMOGRAM @17/08/21


RFT @ 17/08/21



LFT @17/08/21



CUE



USG ABDOMEN



CHEST XRAY




FEVER CHARTING


TREATMENT GIVEN 

 DAY 1


DAY 2 



Provisional diagnosis:

DENGUE ( NS1 POSITIVE ) WITH THROMBOCYTOPENIA










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