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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
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CHEIF COMPLAINTS OF FEVER SINCE 8 DAYS AND RASH SINCE 1 DAY( 26/10 /22)
HOPI: A 17 YEAR MALE CAME TO THE OPD WITH CHEIF COMPLAINTS OF FEVER , HIGH GRADE CONTINOUS TYPE, ASSOCIATED WITH CHILLS AND RIGORS SINCE 7 DAYS.
NOT ASSOCIATED WITH COLD , COUGH, PAIN, BURNING MICTURATION, HEADACHE
H/O RETRO ORBITAL PAIN DURING THE EPISODES OF FEVER.
H/0 RASH OVER THE BODY SINCE YESTERDAY MORNING, MACULOPAPULAR RASH.
NO C/O BLEEDING FRIM GUMS,NOSE, RECTUM,BLOOD IN URINE.
ON DAY 1 OF FEVER , PATIENT WAS TAKEN TO RMP AND TOOK ORAL MEDICATION UPON WHICH , FEVER SUBSCIDED.
PAST HISTORY
NOT A KNOWN CASE OF DM/HTN /TB/ ASTHAMA/ EPILEPSY/CAD
NO SIMILAR COMPLAINTS IN PAST
PERSONAL HISTORY
DIET- MIXED
APPETITE -NORMAL
BOWEL AND BLADDER MOVEMENTS-REGULAR
NO BURNING MICTURATION
NO ALLERGIES, ADDICTIONS
FAMILY HISTORY: INSIGNIFICANT
GENERAL EXAMINATION
PATIENT CONSCIOUS, COHERENT, COOPERATIVE ORIENTED TO TIME ,PLACE AND PERSON
MODERATELY BULIT AND NOURISHED
ON EXAMINATION
THERE WAS NO PALLOR , ICTERUS, CYANOSIS , CLUBBING, LYMPHADENOPATHY
SUB CONJUNCTIVAL HEMORRHAGES PRESENT
VITALS:
TEMP- 100F AT THE TIMEOF ADMISSION
PULSE RATE- 96BPM
RESPIRATORY RATE- 17CPM
BLOOD PRESSURE -110/70MMHG
GRBS-112MG/DL
SYSTEMIC EXAMINATION:
CVS: S1; S2 +
NO THRILLS AND MURMURS
RESPIRATORY SYSTEM: BAE+
PER ABDOMEN- SOFT , NON TENDER ,BOWEL SOUNDS PRESENT
CNS: HMF INTACT AND NFAD
S:Abdominal pain in epigastric region
O:Fever spike 1@2am- 101°f
O/E- pt is in sitting position
Afebrile
PR-84bpm
RR-19cpm
BP-110/70mmhg
SPO2-97%@RA
CVS-S1,S2 +
RS- BAE+,NVBS
P/A- soft,BS+
CNS- HMF intact
Plenty of oral fluids
IVF- NS,RL
INJ. Neomol 1g/IV/SOS
Tab. DOLO 650mg/PO/TID
Tab. LEVOCITRIZINE 10mg/PO
Vitals and Temp charting 4th hourly
Day 2
S: Burning sensation of soles while walking,
Itching all over the body
O:No Fever spikes
O/E- pt is in sitting position
Afebrile
PR-78bpm
RR-18cpm
BP-110/70mmhg supine
_100/70 on standing
SPO2-97%@RA
CVS-S1,S2 +
RS- BAE+,NVBS
P/A- soft,BS+
CNS- HMF intact
Diagnosis: viral pyrexia with thrombocytopenia with rash
Mild pleural effusion with mild ascites
Plenty of oral fluids
IVF- NS,RL@50ml /hr
INJ. Neomol 1g/IV/SOS if temp > 101f
Tab. DOLO 650mg/PO/TID
Tab. LEVOCITRIZINE 10mg/PO
Vitals and temperature charting
Day 3
S: Burning sensation of soles while walking,
Itching all over the body
O:No Fever spikes
O/E- pt is in sitting position
Afebrile
PR-78bpm
RR-18cpm
BP-110/70mmhg supine
_100/70 on standing
SPO2-97%@RA
CVS-S1,S2 +
RS- BAE+,NVBS
P/A- soft non tender,,BS+
CNS- HMF intact
Diagnosis: viral pyrexia with thrombocytopenia with rash
Mild pleural effusion with mild ascites
Plenty of oral fluids
IVF- NS,RL@50ml /hr
INJ. Neomol 1g/IV/SOS if temp > 101f
Tab. DOLO 650mg/PO/TID
Tab. LEVOCITRIZINE 10mg/PO
Vitals and temperature charting
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