19 year old male


      ELOG BASED CASE STUDY

Date: 31/08/21

A 19r old male patient came with chief complaints of fever since 5 days.

Patient was apparently asymptomatic 5 days back then he developed high grade fever, which was intermittent , decreased on medication. He developed abdominal discomfort since three days, vomitings 4-5 episodes which was non bilious and non projectile with food particles as a content.

Loss of appetite since three days and constipation since three days.

No C/O cough, cold, SOB

No H/O giddiness/ blurring of vision

No h/o HTN, DM, CVA, CAD,TB, epilepsy.

Personal history:

Decreased appetite

Bowel movements  - decreased ( constipation) and bladder movements are normal

Known alcoholic - beer since one year ( occassionally)

General examination:

The patient is conscious coherent and cooperative

Moderately built and moderately nourished. 

Vitals:

PR:102pm

BP:90/60 mmHg

RR:16cpm

Spo2:98% at RA

P/A: 

Shape of abdomen: scaphoid

Non tender

Liver and spleen - not palpable

Bowel sounds are present

CVS: S1, S2 +

RS: BAE + , NVBS +

CNS: NFND

Investigations:

HEMOGRAM


MP STRIP TEST:

LFT

RBS


SERUM ELECTROLYTES

CHEST XRAY

ULTRASOUND ABDOMEN.


Provisional diagnosis:

Viral pyrexia with thrombocytopenia (?  Dengue)

Treatment:





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