19 year old male with viral pyrexia

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS 

CASE
This is a case of 19 year old student who presented to the OP with the chief complaints of 
★Fever since yesterday
★Headache since yesterday 
★ Generalised weakness 
History of present illness
The patient is apparently asymptotic till yesterday then he developed fever which is of high grade, intermittent associated with chills and rigors . 
There is no history of Cold, cough, sore throat, nausea or vomitings.
No history of photophobia, watering of eyes
There is no history of Burning micturition, hematuria, Malena, pain abdomen, epistaxis 
No history of chest pain, palpitations or syncopal attacks 

PAST HISTORY 
Not a known case of DM/HTN/TB/CAD/ Epilepsy/Asthma 

PERSONAL HISTORY 
DIET- mixed 
APETITE- normal 
SLEEP-adequate 
BOWEL AND BLADDER MOVEMENTS - regular 
ADDICTIONS -none 

FAMILY HISTORY 
Not significant 

GENRAL EXAMINATION

The patient is coherent, conscious,cooperative well oriented to time place and person 
He is moderately built and nourished 
PALLOR -absent 
ICTERUS -absent 
CYANOSIS -absent 
CLUBBING -absent 
EDEMA -absent 
LYMPHADENOPATHY -absent 

VITALS 
TEMP-103F
PR-92bpm
RR -18 cpm
BP-120/80
Spo2-98

SYSTEMIC EXAMINATION 
CVS-S1S2 heard 
CNS-Higher mental functions intact 
PA-Soft and non tender 
RS- BAE+

DIAGNOSIS 
Viral pyrexia 

INVESTIGATIONS 
Malarial parasite -ve 

                            X - ray
.                                ECG

                           HEMOGRAM
                               CUE         
                        ELECTROLYTES
                                  LFT

TREATMENT 

★Inj Neomal 1gm/IV/SOS

★IVF NS and  RL  @75ml/hr

★Tab dolo 650mg Po/QID

★Look for postural drop of BP and bleeding manifestation

★Temp/BP/PR chatting 4th hourly

★Inform SOS


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