23 yr old male with complaints of fever

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Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 a diagnosis and treatment plan.

Chief complaints:

23 year old male, resident of suryapet came to the OPD with the Cheifcomplaints of  fever since 4days,loss of appetite since 4days

HOPI: Patient was apparently asymptomatic 4days ago later he developed fever which is insidious in onset, intermittent type,associated with headache  ,associated with chills and rigors,relieved with medication

Past history:

N/K/C/O HTN,DM,TB,CAD,ASTHMA

GENERAL EXAMINATION 

Patient is Conscious, coherent,co operative well oriented to Time,place,person

No pallor, No icterus, No Cyanosis, No Lymphadenopathy, No Edema

VITALS

Temperature -102.7F

Pulse rate- 108bpm

Blood pressure-120/70mm hg

Respiratory rate -16cpm

SYSTEMATIC EXAMINATION:

PER ABDOMEN:Soft, non tender

No guarding, No rigidity 

Bowel sounds present 

CARDIOVASCULAR SYSTEM:

S1,S2 heard, NO Murmurs 

RESPIRATORY SYSTEM:

BAE present,NVBS

CENTRAL NERVOUS SYSTEM:

NAD

PROVISIONAL DIAGNOSIS-DENGUE FEVER WITH THROMBOCYTOPENIA

INVESTIGATIONS 

5/4/22:

Hemogram:

Hb 13.9gm/dL 

TC-1100

N/L/E/M-42/47/1_10

PLT: 80000/mm3

LFT:

TB :0.69

DB:0.20

SGOT :137

SGPT:45

ALP: 113

Serum Creat : 1.3

Serum Urea-20

RBS-120mg/dl

Serum electrolytes

Na - 139

K- 3.5

Cl- 99

Treatment 

1)IVF NS, RL at 100ml/hr

2)INJ PANTOP40mg IV OD

3)INJ ZOFER 4mg IV SOS

4)TAB DOLO 650mg PO TID

5)INJ NEOMOL 1gm IV SOS

6)INJ OPTINEURON 1ampule in 100ml NS/IV/OD

7)PLENTY OF ORAL FLUIDS

Soap notes day 1 (6/4/22)

S- fever spikes present

O: Patient is Conscious, coherent,co operative well oriented to Time,place,person

No pallor, No icterus, No Cyanosis, No Lymphadenopathy, No Edema

VITALS

Temperature -102F

Pulse rate- 84bpm

Blood pressure-120/80mm hg

Respiratory rate -16cpm

SYSTEMATIC EXAMINATION:

PER ABDOMEN:Soft, non tender

No guarding, No rigidity 

Bowel sounds present 

CARDIOVASCULAR SYSTEM:

S1,S2 heard, NO Murmurs 

RESPIRATORY SYSTEM:

BAE present,NVBS

CENTRAL NERVOUS SYSTEM:

NAD

5/4/22:

Hemogram:

Hb 13.9gm/dL 

TC-1100

N/L/E/M-42/47/1_10

PLT: 80000/mm3

LFT:

TB :0.69

DB:0.20

SGOT :137

SGPT:45

ALP: 113

Serum Creat : 1.3

Serum Urea-20

RBS-120mg/dl

Serum electrolytes

Na - 139

K- 3.5

Cl- 99

6/4/2022:

HEMOGRAM

Hb :13.9

TLC 1,230

PLT -40,000

7/04/2022:

HEMOGRAM

Hb:14.7

TLC -1,550

PLT- 35,000  

A:

DENGUE FEVER WITH THROMBOCYTOPENIA 

P:

1)IVF NS, RL at 100ml/hr

2)INJ PANTOP40mg IV OD

3)INJ ZOFER 4mg IV SOS

4)TAB DOLO 650mg PO SOS

5)INJ NEOMOL 1gm IV SOS

6)INJ OPTINEURON

7)PLENTY OF ORAL FLUIDS

Soap notes day 2(7/4/22)

S- fever spikes present

O: Patient is Conscious, coherent,co operative well oriented to Time,place,person

No pallor, No icterus, No Cyanosis, No Lymphadenopathy, No Edema

VITALS

Temperature -101F

Pulse rate- 84bpm

Blood pressure-120/80mm hg

Respiratory rate -16cpm

SYSTEMATIC EXAMINATION:

PER ABDOMEN:Soft, non tender

No guarding, No rigidity 

Bowel sounds present 

CARDIOVASCULAR SYSTEM:

S1,S2 heard, NO Murmurs 

RESPIRATORY SYSTEM:

BAE present,NVBS

CENTRAL NERVOUS SYSTEM:

NAD

5/4/22:

Hemogram:

Hb 13.9gm/dL 

TC-1100

N/L/E/M-42/47/1_10

PLT: 80000/mm3

LFT:

TB :0.69

DB:0.20

SGOT :137

SGPT:45

ALP: 113

Serum Creat : 1.3

Serum Urea-20

RBS-120mg/dl

Serum electrolytes

Na - 139

K- 3.5

Cl- 99

6/4/2022:

HEMOGRAM

Hb :13.9

TLC 1,230

PLT -40,000

7/04/2022:

HEMOGRAM

Hb:14.7

TLC -1,550

PLT- 35,000  

A:

DENGUE FEVER WITH THROMBOCYTOPENIA 

P:

1)IVF NS, RL at 100ml/hr

2)INJ PANTOP40mg IV OD

3)INJ ZOFER 4mg IV SOS

4)TAB DOLO 650mg PO SOS

5)INJ NEOMOL 1gm IV SOS

6)INJ OPTINEURON

7)PLENTY OF ORAL FLUIDS

Soap notes (8/4/22)

S- fever spikes absent

O: Patient is Conscious, coherent,co operative well oriented to Time,place,person

No pallor, No icterus, No Cyanosis, No Lymphadenopathy, No Edema

VITALS

Temperature -98F

Pulse rate- 82bpm

Blood pressure-120/80mm hg

Respiratory rate -17cpm

SYSTEMATIC EXAMINATION:

PER ABDOMEN:Soft, non tender

No guarding, No rigidity 

Bowel sounds present 

CARDIOVASCULAR SYSTEM:

S1,S2 heard, NO Murmurs 

RESPIRATORY SYSTEM:

BAE present,NVBS

CENTRAL NERVOUS SYSTEM:

NAD

5/4/22:

Hemogram:

Hb 13.9gm/dL 

TC-1100

N/L/E/M-42/47/1_10

PLT: 80000/mm3

LFT:

TB :0.69

DB:0.20

SGOT :137

SGPT:45

ALP: 113

Serum Creat : 1.3

Serum Urea-20

RBS-120mg/dl

Serum electrolytes

Na - 139

K- 3.5

Cl- 99

6/4/2022:

HEMOGRAM

Hb :13.9

TLC 1,230

PLT -40,000

7/04/2022:

HEMOGRAM

Hb:14.7

TLC -1,550

PLT- 35,000  

A:

DENGUE FEVER WITH THROMBOCYTOPENIA 

P:

1)IVF NS, RL at 100ml/hr

2)INJ PANTOP40mg IV OD

3)INJ ZOFER 4mg IV SOS

4)TAB DOLO 650mg PO SOS

5)INJ NEOMOL 1gm IV SOS

6)INJ OPTINEURON

7)PLENTY OF ORAL FLUIDS