A 20 YEAR OLD MALE PATIENT:-

This is an online E log book to discuss our patients de- idendentified health data shared after taking his guardian's signed form consent. Here we discuss our individual patients problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e- log book also reflects my patient centered online learning  protofolio and your valuable inputs on comment box is welcome.

A 2o year male patient daily labourer by occupation came to casuality with chief complaints of fever & headache since yesterday.

HISTORY OF PRESENT ILLNESSES:-

Patient was apparently  asymptomatic since yesterday came with compliants of fever around yesterday night ,high grade fever associated with chills & rigor on,off relieved on medication,no history of cold,cough.

History of headache since yesterday,pain in frontal region, throbbing type of pain, during episodes of fever,photophobia +& phonophobia + aggrevating with position variation, lacrimation (-)diplopia(-).

No history of nausea, vomiting,loose stools 

No history of chest pain, palpitation,syncopal attacks.

No history of sob,orthopnea, palpitation

No history of pedal edema,facial puffiness

No history of burning micturition.

HISTORY OF PAST ILLNESS:-

No history of similar compliants in the past

Not a known case of DM, HTN,TB,Asthma, epilepsy.

No history of previous surgeries & no history of previous blood transfusions.

PERSONAL HISTORY:-

Diet:- mixed

Appetite:- normal

Bowel movements:- normal

Micturition:- normal

Addictions:- 

Not an alcoholic

No smoking

FAMILY HISTORY:- 

There are no similar compliants in the family members.

VITALS:-

pulse rate:- 84BPM

RR:- 18 CPM

Bp:-90/60 mm of Hg

SpO2:-99%at RA

GRBS:- 99mg/dl

TREATMENT HISTORY:-

- He is not a known case of any drug allergy.

GENERAL EXAMINATION:-

 Patient is conscious, coherent, cooperative at the time of joining.

Patient is thin built & malnourished.

- no pallor

- no icterus

- no cyanosis

-no clubbing of fingers and toes

- no lymphadenopathy

- no pedal edema

SYSTEMIC EXAMINATION:-

CVS:-S1& S2 heard,no murmurs

RS:- position of trachea :- central

BAE:+

NVBS heard

P/A :- soft ,non tender, no palpable masses or swelling.

CNS :- NAD.

DIAGNOSIS:-

Dengue

ECG:-


Fever chart :-


Hemogram


Dengue antigen test


ESR:-


Malaria parasite:-


CUE:-


Serum protein:-


SGPT:-


SGOT:-


SERUM BILIRUBIN:-


SERUM CREATININE:-

SEROLOGY:-



Diagnosis:- Dengue

Treatment given:-

1)IV fluids

2)tab pcm 650mg po/tid

3)Inj neomol 1h/iv/sos

4)Inj pan 40mg/po/od

5)Inj zofer 4mg iv/ sos








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