22M WITH DENGUE AND BICYTOPENIA
This is an online e log book to discuss our patient de-identified health data shared after taking his /her guardian signed informed consent. Here we discuss our individual patients problems with collectors 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.
A 22 year old male patient(student),who is a resident of narketpally came to OPD with
CHIEF COMPLAINTS :
fever associated with chills and rigors ,headache ,burning sensation of eyes
HISTORY OF PRESENT ILLNESS:
Patient was apparently assymptomatic 5 days back,then he developed fever with chills which was sudden in onset.Even after he used paracetamol the fever continued .he then rushed to the hospital
DAILY ROUTINE:
He stays in hostel.He wakes up at 8 AM ,he brushes his teeth goes to the washroom then goes for a bath.
After having breakfast he goes to clg at 9 AM. He then has his lunch at 2:00 PM. After that he hang out with his friends.he will.have his dinner at 8:00 Pm and sleeps by 9:00 PM.
ON THE DAY OF INCIDENCE:
After his lunch he suddenly felt feverish which was associated with chills .he then had medication(dolo) which didnt have any effect. So he rushed to the hospital.
PAST HISTORY :
N/K/O: diabetes ,hypertension, epilepsy,Tb,thyroid abnormalities,asthma
PERSONAL HISTORY:
Diet: mixed
Appetite: normal
Sleep: adequate
Bladder movement: normal
Bowel movement:normal
Occasionally consumes alcohol.
FAMILY HISTORY:
insignificant family history
GENERAL EXAMINATION:
prior consent was taken and patient was examined in a well lit
room
patient was conscious ,coherent and cooperation
pallor present , No icterus, clubbing, cyanosis
No generalised lymphadenopathy
No pedal edema
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
DENGUE ASSOCIATED WITH THROMBOCYTOPENIA AND LEUKOCYTOPENIA