GENERAL MEDICINE CASE

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I'm Thota Vaishnavi of 3rd sem, roll no. 133.
Below is an E-log describing patient centered data approach and discussion regarding patient de- identified health data.

Case 1 :
A 17 year old boy presented with chief complaints of :
• Fever since 3 days
• Generalized weakness since 3 days
• Headache since 3 days
• Pain in abdomen since 2 days
• Vomiting yesterday morning 
• Nausea since yesterday.

History of present illness  :

• A 17 year old boy, btech 2nd year student in Hyderabad, presented with low grade intermittent fever since past 3 days with no diurnal variation.
• Over the past 3 days he has also been experiencing generalized weakness along with diffuse intermittent headaches.
• Since 2 days he even complains of diffuse pain abdomen and also had 2 episodes of loose stools each day for 2 days which were watery in consistency, yellowish, non blood tinged.
• He had 1 episode of non projectile, non bilious, vomiting with food content yesterday morning.
• He also complains of nausea since yesterday.

History of past illness :
• Not a known case of DM, HTN, CAD, 
• Not a known case of epilepsy, TB, asthma, thyroid disorders.

Personal history : 
• Lost appetite since 3 days
• Diet - Non-vegetarian 
• Regular bowel moments 
• Normal micturition 
• No know allergies 

Family history :
No significant family history.

General examination :
• Patient is conscious, coherent and cooperative.
• Moderately built
• No pallor, cyanosis, icterus, clubbing, lymphadenopathy, pedal edema.
• No malnutrition 
• Mild dehydration 

Vitals :
PR : 94 bpm
BP : 100/70 mm Hg in standing position.
120/90 mm Hg in supine posture.
Temperature: 99°F
SPO2: 99% at room temperature 
GRBS: 104 mg%

Per abdomen  :
Shape of abdomen: scaphoid
Palpable mass: No
Hernial orifices: Normal
Free fluid: Yes
Bruits: No
Liver : not palpable 
Spleen : not palpable
Diffuse tenderness +
Bowel sounds +

CVS :
S1, S2 heard
No murmurs
No thrills

Respiratory system :
No dysnea
No wheeze
Position of trachea- central
Breath sounds- vehicular 
Lungs clear on auscultation.

Central nervous system :
Speech - normal
No meningeal irritation 
Motor and sensory system - normal
Cranial nerves - intact
Reflexes - present 

Investigations :

Dengue NS1 positive

Hemogram :
Impression :  NC/NC BP with LEUKOPENIA and THROMBOCYTOPENIA
LFT :
Serum creatinine :
Blood grouping and RH type :
Serum electrolytes :
Blood Urea :
Temperature :


Provisional diagnosis :
Viral pyrexia with thrombocytopenia.

Treatment :
1. Advised plenty oral fluids.
2. IV - 20 NS @ 125 ml/hr
         - 10 RL @ 125 ml/hr
3. Inj PANTOP 40mg IV/OD
4. Inj ZOFER 4mg IV/TID
5. Inj NEOMAL 10mg IV/SOS
6. Tab DOLO 650mg PO/TID 1-1-1
7. TEMP/BP/PR/GRBS 4th hourly 
     STEPID SPONGING
8. W/F BLEEDING MANIFESTATIONS 
9. HEMOGRAM 12th HOURLY 
10. POSTURAL HYPOTENSION 4th HOURLY 
11. MONITOR VITALS
12. STRICT I/O CHARTING

Final diagnosis :
Dengue fever with thrombocytopenia. 


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