16 yr old male pt presented to medicine op with chief complaints of fever, generalized pain abdomen, vomiting and generalized weakness.

This is an E-log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed . I have been given this case, in an attempt to solve and understand the topic of "Patient's clinical data analysis”. This has helped me develop my competency in reading and comprehending clinical data including history taking, clinical findings and investigations. The goal is to come up with a diagnosis and treatment plan.

This is a case of a 16 yr old male pt presented to medicine op on 26th October 2021 
with chief c/o fever since 4 days  
c/o generalized pain abdomen since 4 days c/o vomiting since 3 days 
c/o generalised weakness since 4 days

History Of Presenting Illness:
Pt was apparently asymptomatic 4 days back , then he developed a low grade fever, intermittent in nature, not a/w chills and rigors, which was relieved on taking medications. 
He also developed generalized pain abdomen since 4 days which was intermittent in nature and squeezing type of pain. 
He c/o generalised weakness since 4 days. 
He developed vomiting since 3 days numbering to 2 episodes(non bilious, non projectile), which aggrevated on food intake and relieved on medications and glucose IV. He developed maculopapular rashes on thorax since 2 days.
No H/o itching, burning micturition, hematuria, hematemesis. 
Not a k/c/o DM /htn / tb / asthma / epilepsy.   

Past History: 
H/o typhoid 2 yrs back which was relieved on medication. 

Personal history: 
Diet- mixed 
Sleep- adequate 
Appetite- reduced since 4 days 
Bowel and bladder movements- regular Addictions- none 

Family history: 
H/o DM in paternal side (uncles) 
No H/o Asthma, HTN 
 
General Examination: 
Pt. is Concious/Coherent/Cooperative 
 
Vitals 
PR: 64 bpm  
BP: 100/70 mmHg 
RR: 16 cpm  
Temp: Afebrile 
SPO2: 100% at room air 
  
O/E
No signs of pallor, icterus, cyanosis clubbing, edema, lymphadenopathy.
Systemic Examination: 

1. CVS - S1 S2 +. No murmurs 

2. RS- BAE+ , NVBS+, centrally positioned trachea 

3. P/A- scaphoid, soft, non tender 

4. CNS- 

Level of consciousness- Concious/Alert 

Speech: Normal 
Normal cranial nerves, motor system, sensory system Neck stiffness- absent

Normal Reflexes. Rt. Lt Biceps. + + Triceps. + + Supinator. + + Knee. + + Ankle. + + Plantar: flexor 

Cerebral Signs:Finger Nose and Heel Knee in coordination 
Normal Gait
Normal #Musculoskeletal system, Skin, ENT, Teeth and oral cavity, Head and neck examinations revealed normal results. 

 Provisional Diagnosis: Viral pyrexia secondary to Dengue 
 
Investigations: 
Blood for MP strip: Negative 
NS1 Antigen:Positive 
IgM: Positive 


Hemogram: 
Hb-14.3 
TLC-2700 
MCV-81.0 
MCH-26.9 
PCV-43.0 
PLC-60,000 
NORMOCYTIC NORMOCHROMIC
CUE: 
Albumin- nil 
Sugar- nil 
RBC Cast- nil 
Pus Cells- 2-4 
Epithelial cells- 2-3
LFT: 
TB- 0.71 
DB- 0.20 
SGOT- 213 
SGPT-126 
ALP-566 
Total Protein- 5.6 
Albumin- 2.8 

RFT: 
Blood Urea-13 
S. Creatinin- 0.7  
Na- 137 
K- 4.0 
Cl- 198 

ECG: Normal findings
Radiograph: AP view of chest X-Ray with no anomalies.
Ultrasonography:
Shows 
# Mild Ascites 
# Gall Bladder wall Oedema
THIS IS A CASE OF VIRAL PYREXIA WITH THROMBOCYTOPENIA SECONDARY TO DENGUE 

Treatment: 
1. IVF- NS & RL @75ml/hr 
2. Inj. PAN 40mg OD 
3. Inj. Opineuron 1 amp in 100 ml NS IV/ OD 4. Inj. ZOFER 4mg IV/BD 
5. BP, PR, SPO2 monitoring 4th hourly 
6. Strict I/O monitoring 
7. GRBS monitoring at 8am in the morning 
8. Inform SOS 
9. Inj. TAXIM 1g IV/BD 
10. TAb. Doxycycline 100g BD

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