19 year old with viral pyrexia

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect6current best evidence based input
This Elog also reflects my patient centered online learning portfolio.
Your valuable inputs on 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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever

Under the guidance of 

Dr. Vinay PGY3

Dr.Venkat Sai PGY1

This is a case of 19 year old student who presented to the OP with the chief complaints of 

1)Fever since yesterday

2)Headache since yesterday 

3) Generalised weakness 

The patient is apparently asymptotic till yesterday ,

Then he developed :

* Fever which is of high grade, intermittent associated with chills and rigors 

* No history of Cold,cough,sore throat, nausea or vomitings 


* Headache in the frontal region of   Episodes per day 

* No history of photophobia, 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 


RBS -99

Blood urea- 28

Sr creatinine-1.0










TREATMENT 

1)Inj Neomal 1gm/IV/SOS

2)IVF NS and  RL  @75ml/hr

3)Tab dolo 650mg Po/QID

4)Look for postural drop of BP and bleeding manifestation 

5)Temp/BP/PR chatting 4th hourly

6)Inform SOS

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