30 yr male

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This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems 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 inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome



A CASE OF 30 YEAR OLD MALE PATIENT 

 

A 30 year old male patient came with the chief complaints of

Complaints of fever, body pains, neck pain since 3 days. H/o dark coloured stools since 2 days.


History of presenting illness:

Patient was apparently asymptomatic 1 week ago following which patient develop fever high-grade associated with chills and headache for which he went to a local RMP doctor and there medications were given and he was sent back home but the fever did not relieve and so he went to nalgonda hospital where investigations were done and patient was found to be positive and medications were given and was put on NS IV for due to money issues he went back home. He was fine that night and the fever recurred the next day and so he came to kims on 3/12/21.

H/O three episodes of dark coloured loose stools, vomiting 1 episode that morning which was non bilious, non projectile and food particles as content.


History of past illness:

Not a k/c/o DM, HTN, TB, BA, CAD, CVA.


Personal history:

Occupation: farmer

Diet: Mixed

Appetite: normal

Sleep: adequate 

Bladder: burning micturition+

Addictions: occasionally drinks beer.


Physical examination:

Patient C/C/C

No signs of pallor, icterus, clubbing, cyanosis, edema, lymphadenopathy.


Vitals:

Temperature: afebrile

BP: 110/70 mmhg

PR: 78bpm

RR: 16cpm

Spo2: 98%.


Systemic examination:

CVS: S1 and S2 heard

RS: bae+ 

P/A: soft, non tender.

CNS: NAD.


Investigations:

Cbp on 3/12/ 21 
Hb- 17
TLC- 4600
Plt. Count- 46000
RBS- 148
Rft:
Urea- 45
Sr. Cr- 1.2
Na+: 140
K+ : 3.7
Cl- : 97
Lft:
TB-0.8
SGOT-48
SGPT-29


BGT- AB+


Cbp on 4/12/21
Hb- 15.7
TLC- 6500
Plt. Count- 13000

Transfusion done on 4/12/21
Cbp on 5/12/21, 12:30am
Hb- 14.0
TLC- 7800
Plt. Count- 60,000

Cbp on 5/12/21, 9:55 am
Hb- 14.4
TLC- 8500
Plt count- 38,000.

Diagnosis:
Dengue fever (NS1 positive)with thrombocytopenia.

Treatment:
1) Plenty of oral fluids 
2) IVF NS and RL at 150 ml/hr
3) T. PAN 40 MG PO OD
4) T. PCM 650MG PO TID
5) ORS sachets in 1 liter water. Drink 200 after each loose stool
6) INJ. OPTINEURON 1 AMP IN 100 ML NS IV OD
7) INJ. ZOFER 4 MG IV SOS
8) T. SPOROLAC DS PO TID
9) BP/PR/ Temp charting 4th hourly
10) strict I/o charting







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