19 year old male came to Opd with chief complaint of fever sinces 3 days
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I have 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 diagnosis and treatment plan
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Chief complaints:
A 19 year old male came to Opd with chief complaint of fever
Patient went to local hospital for treatment of fever
And he diagnosed of dengue fever then he came to Opd
History of present illness
patient was asymptomatic 3days back. Then he develop fever associated with headache, eyepain, fever intermittent Spike of temperature every 2 hours reduced on taking medication, fever is associated with join pains, chills.
and 1 episode of vomiting (non billius) 2 days back
Past history:-
No similar complaints in the past
Not a know case of DM,ASTHMA,HTN,EPILEPSY,TB
Personal history
Diet:mixed
Appetite:normal
Bowel and bladder movements:normal
Appetite : decreased
Sleep : adequate
No additions
Past history
No diabetes and hypertension
On examination:-
Pt is C/C/C well oriented to Time ,place and person
No pallor,icterus,cyanosis,clubbing,or generalised lymphadenopathy
febrile
BP-120/90 mmHg
PR-90 bpm
RR-25cpm
CVS-S1S2 heard
R/S - BAE +
CNS-NFND
P/A
Inspection-
Shape of abdomen normal
Umbilicus -central and inverted
No visible scars,sinuses,dilated veins
Hernial orifices normal
Palpation -no local rise of temperature
No Tenderness present
No guarding,rigidity,rebound tenderness
No hepatomegaly,spleenomegaly
Percussion-
Resonant
Auscultation-
Bowel sounds +
Investigations-
Hb-14.8
TLC-2,200
Neutrophils-61
Lymphocytes-30
Eosinophils-01
Monocytes-08
Basophils-00
Platelet count-68000
CUE-
Serum creatinine -0.9mg/dL
Blood urea-13 mg/dL
LFT-
Total bilirubin -0.85 mg/dL
Direct bilirubin-0.19
AST-257 IU/L
ALT-128 IU/L
Alkaline phosphate- 123 IU/L
Total proteins-5.99 gm/dL
Albumin-3.6gm/dL
A/G ratio-1.68
Serum electrolytes and ionised calcium-
Sodium-136 mEq/L
Potassium-3.4
Chloride-98
Calcium ionised-0.84mmol/L
Serology (anti hcv ab,HbsAg ,HIV 1/2 rapid) :negative
Ultrasound:-
Treatment:-
