26 yr old male with fever

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CBBLE UDHC Similar case



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 global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."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



26 yr male mechanic by occupation came with c/o fever , since 5 days which is high grade , associated with chills , intermittent, relieved with medication . 
No h/o vomitings, loose stools, burning micturition. 
No h/o of sob, cough, cold 
No h/o bleeding manifestations

PAST HISTORY : N/k/c/o of Dm, HTN, CAD , TB, BA, Epilepsy. 
No previous surgeries . 

O/E
 pt is c/c/c
Temp : 98.1 f
PR : 84 bpm 
RR : 16 cpm.
BP : 110/70 mm hg
Spo2 : 98 %@ RA
grbs : 105 mg/dl 

CVS : s1 s2 + 
RS : BAE + NVBS
CNS : NAD
P/A : soft &  non tender 

INVESTIGATIONS : 

HB : 19.7 
TLC: 3,000
PCV:57
PLT:20,000
N/L/M/E/B: 54/34/10/2/0
RBC:6.05 

UREA: 22
SR.CR:1.2
Na+:140
K+: 4.3
Cl+: 99

TB: 1.83
DB: 0.95
AST: 51
ALT:20
ALP: 128
TP: 5.5
ALB: 3.4
Dengue NS 1 : +VE 
MP : - ve .

DIAGNOSIS : Dengue fever 

TREATMENT : 

18/3/22

1)IVF NS, RL, @ 150 ml/hr,  DNS @ 100 ml / hr 
2)Inj. PAN 40 mg i.v OD 
3)inj. ZOFER 4 mg /i.v/ sos 
4)Inj. OPTINEURON 1amp in 100 ml NS /i.v/OD
5)Tab. DOLO 650 mg po/sos
6) Inj. NEOMOL 1gm /i.v/ sos

19/3/22
CST

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