CASE DISCUSSION OF 32 YR MALE WITH FEVER,HEADACHE,COUGH

Name:T RAJESH
BATCH:2017

I've 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.


CASE DISCUSSION

CHIEF COMPLAINTS::
32 yrs male came to opd with chief complaints of 
      Fever since 7 days
      Cough since 7 days
      Headache since. 7days
      Giddiness since 7days

HISTORY OF PRESENT ILLNESS::

Fever was intermittent,,on and off  
Aggregated.during night
Associated with chills
Relieved on medication

 Cough. Sudden in onset
Gradually progressive
Non productive

Headache is diffuse 
Not associated with photophobia,dizziness

Giddiness   is present mainly on getting up from bed

Routine history 

He generally wakes up morning and goes to work (construction)
All the day was normal before onset of symptoms
But noticed onset of fever before coming to opd which was more during night
His work was not disturbed with onset of fever
But severe fever in night lead him to hospital admission.

History of past illness

No similar complaints in past

No h/o dm,htn,bronchial asthma,epilepsy,thyroid problems.

Personal history

Appetite:normal
Diet:mixed
Bowel and bladder:regular
Addictions:.  Alcoholic since 6 years(occasionally)

Treatment history                

Not treated previously for any disease

Drug history        

No known allergies to any drug

No food allergy


GENERAL EXAMINATION

After taking consent
Patient examined in a well lighted room
Patient was conscious,coherent, cooperative
Built :moderate

No signs of :::
PALLOR
ICTERUS
Cyanosis
Clubbing of fingers
Lymphadenopathy
Odema(of feet) 

Vitals::::

Bp:110/70
Respiratory rate:20c/min
Temperature:98.8 F
Pulse rate:62
Spo2 at room air:98

Systemic examination::

Respiratory system:

Position of trachea:central
Shape of chest:B/L symmetrical
No dyspnoea
No wheeze


Cvs::

S1,S2 heard
No murmurs

Abdomen::

Inspection:shape of abdomen:SCAPHOID
palpation:
Tenderness:no
No abnormal palpable mass
Bowel sounds:not heard
Liver and spleen not palpable

CNS::

Conscious
Neck stiffness:not present
Kerning sign : -ve
Giat:normals
Sensory and motor system':intact

Investigations:::

CBP:
Cue:
NS1ANTIGEN TEST: NEGATIVE
IGM antibody: POSITIVE

ultrasound abdomen:
Reason for Ascites and gall bladder wall oedema::

ECG:
Pathogenesis::
Provisional diagnosis:: 

DENGUE FEVER WITH THROMBOCYTOPENIA

Management:::

IVF..NS/RL..
Inj.pantop.40mg /iv/od
Tab:dolo 650mg Tid
Syp:GRINLLINCTUS 10ml/bd

Monitor vitals
Check platelets,pcv 12th hourly.




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