17 year male with complaints of fever and rash


THIS IS AN ONLINE E-LOG BOOK TO DISCUSS OUR PATIENT DE- IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIANS SIGN INFORMED CONSENT.HERE WE DISCUSS OUR INDIVIDUAL PATIENT PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIMTO SOLVE  THOSE PATIENT CLINCAL PROBLEM WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS .

THIS E-LOG ALSO REFLCTS MY PATIENT CENTERED ONLINE LEARNING PORTFOLIO.

YOUR VALUABLE INPUTS ON COMMENT BOX IS WELCOME . I HAVE BEEN GIVEN THIS CASE TO SOLVE IN AN ATTEMPT TO UNDERSTAND THE TOPIC OF " PATIENT CLINCAL DATA ANALYSIS_ TO DEVELOP MY COMPETENCY IN READING  AND COMPREHENDING CLINICAL DATA INCLUDING HISTORY, CLINICAL FINDING, INVESTIGATIONS AND COME UP WITH DIAGNOSIS AND TREATMENT PLAN . CAME TO THE HOSPITAL WITH   

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:  felling better , appetite improved
O:No Fever spikes
O/E- pt is in sitting position 
 Afebrile 
PR-80bpm
RR-17cpm
BP-120/70mmhg supine 
_110/70 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 

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