General medicine case 3

 This is an 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 patient's clinical problems with collective current best evidence based inputs

A 18 yr old female presented to the opd with chief complaint of fever , headache and bodypains since 3 days 

HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 3 days back then she had fever which is associated with chills and rigor and subsided on taking medication. Fever is intermittent.

Fever during night times, headche which is not associated with nausea, vomiting.Body pain (diffuse type). Patient was taken to nearby RMP doctor, there she was  diagnosed NS1 antigen positive and referred to our hospital.

PAST HISTORY
There is no history of hypertension,diabetes and thyroid , tb , epilepsy

TREATMENT HISTORY
Patient takes medicine for fever, chills and rigor

PERSONAL HISTORY
- Appetite is normal
- Diet is mixed
- Sleep is adequate
- bowel and bladder movements regular
- No addictions


FAMILY HISTORY
There is no history of similar complaints in the family members.

GENERAL PHYSICAL EXAMINATION
 Patient was conscious, coherent and cooperative  and well oriented to time place and person .Patient is well nourished and well built..
-  No anemia 
- No  pallor 
-  No dyspnea 
- No clubbing
- No cynosis
- No generalized lymphadenopathy
- No Bilateral pedal edema 

VITALS
Temperature - 98.6°F
Pulse rate- 99 /min
Respiratory rate-18/min
Blood pressure-110/90mm Hg
SpO2 at room air- 98%
GRBS- 118 mg%

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Inspection : 

Chest wall is bilaterally symmetrical

No Precordial bulge

No visible pulsations, engorged veins,scars, sinuses

Palpation :

JVP - normal

Apex beat : felt in the left 5th intercostal space

In midclavicular line 

Auscultation :

S1 ,S2 Heard

RESPIRATORY SYSTEM

Bilateral airway +

Position of trachea- central

Normal vesicular breath sounds - heard

No added sounds

PER ABDOMEN

Abdomen is soft and non tender 

Bowel sounds heard

CENTRAL NERVOUS SYSTEM

Patient is conscious 

Reflexes are normal 

Speech is normal

DIAGNOSIS

NS1 antigen positive with thrombocytopenia
 
FINAL DIAGNOSIS
Dengue 

TREATMENT
Inj pantop 40 mg/ IV/OD
Inj zofer 8 mg/ IV/ OD
Tab dolo 650 mg/ TID
Inj Optineuron 1 amp in 100ml NS/IV/OD




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