14yr old female with DENGUE FEVER

April 24, 2022

THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-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.

14 year old female came to OPD with chief complaints of fever since 2 days and vomiting 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 days back then she developed fever which was high grade,intermittent associated with 3 episodes of vomiting (immediately after taking food) .She was taken to a local RMP doctor back when she had high grade fever for which she was given paracetamol.            

The next day she was taken to local hospital as fever hadn't subsided and was under medication after which fever had touch baseline.
No H/O Rash, bleeding manifestations.
 
HISTORY OF PAST ILLNESS:
Not K/C/O HTN, DM, Asthma, COPD, 

PERSONAL HISTORY:

Appetite- lost
Diet- mixed 
Bowel movement- Regular
Micturition- Normal 
Known Allergies- No
No habits of smoking, drinking. 

GENERAL EXAMINATION:
Pallor-mild, No Icterus, Cyanosis, Lymphadenopathy, Edema, clubbing of figures 

Vitals
Pr:74bpm
Bp:140/100
Spo2:98%
Temp - 97.5 F 

SYSTEMIC EXAMINATION:
CVS:
No Thrills, murmurs 
S1,S2+

RS:
No dysponea 
No wheeze 
Clinical images:

Investigations 

PROVISIONAL DIAGNOSIS:
Dengue fever 

TREATMENT:
T• DOLO 650 mg /PO/TID
Syp. ZINCOVIT 10ml/PO/TID
Inj• OPTINEURON lamp in 100ml IV/OD
Inj•ZOFER 4 mg IV/SOS

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