21 year old female patient with fever with chills and body pains

Hi, I am Tejaswi Uppalapati, 3rd semester medical student. This is our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. This elog also reflects my patient centered online learning portfolio.

 A 21 yr old female housewife by occupation came with 


Chief complaints :
1. Fever since 4 days
2. Vomiting 2- 3 episodes/day since 3 days
3. Body pains since 4 days

HOPI :
Patient was apparently asymptomatic 4 days back then she developed fever, more in the evening associated with chills relieved with medication. Then patient started having vomiting since 3 days 2-3 episodes per day with food as contents, non-projectile, non-bilious and not stained with blood. Patient had body pains since 3 days which was more in lower back, hands and legs which was not relieved with medication.
No h/o headache
No h/o diarrhea, vomiting.


Past History :
Not a k/c/o DM,htn,tb,asthma,epilepsy 

On presentation:
Pt conscious,coherent,cooperative,well oriented to time place and person.
General Examination : No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema

PHYSICAL EXAMINATION 

GENERAL EXAMINATION 

Well built

Well nourished

No pallor

No icterus

No cyanosis

No clubbing of fingers

No pedal oedema

No lymphadenopathy

Mild dehydration




VITALS

BP- 110/70mm Hg
PR- 94bpm
RR- 20 cpm
Temp - 98.6
GRBS- 71 mg/dl

Systemic Examination : 

CVS- S1 S2 heard
RS- BAE present
PA - Soft, non-tender
CNS- NAD
Reflexes -
                        Right side    Left side
Biceps -               ++                   ++
Triceps-               ++                  ++
Supinator-           ++                   ++       
Ankle -                 ++                    ++
KNEE-                 ++                    ++

INVESTIGATIONS :

1. Hemogram (12-09-22)

2. RBS

3. Serum Creatinine 

4. Serum electrolytes 

5. Ultrasound 

6. Chest X ray

7. Hemogram (11-09-22)

8. Dengue (NS1) - POSITIVE

9. M. P. Strip test

10. Blood grouping and Rh type :


PROVISIONAL DIAGNOSIS :
DENGUE (NS1 POSITIVE WITH THROMBOCYTOPENIA)


TREATMENT :
1)INJ. NEOMAL 1gm IV if temp > 102°F
2) TAB DOLO 650mg PO/ TID
3) INJ PAN 40mg IV / OD
4) INJ ZOFER 4 mg TID/ SOS
5) IVF 10 RL @ 100 ml/ hr
6) TEMP AND VITALS MONITORING 4th hrly

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