24F Viral pyrexia?

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss out individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective 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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitt



Ch Srinaini

2019

roll no:33


A 24yr old female patient came to the

OPD with chief complaints of fever since 

10 days and cough since two days 


HOPI

Patient was apparently asymptomatic 10 days ago then developed high grade fever with chills and rigors which was continuous type and relieved. Temporarily on IV medication. Fever is mainly during the night time. It is associated with headache, generalised weakness and abdominal pain after having food.

Then developed dry cough since two days occasionally which resolves spontaneously 

No c/o Rash retro orbital pain, cold vomiting, loose stools burning micturation, 

no bleeding manifestations 

No c/o chest pain, SOB ,Palpitations  decreased urine output orthopnea ,PND 


Past History 

H/o appendicectomy

N/K/C/O HTN, DM ,CAD, seizures TB,seizures, asthma 


Personal history

Mixed diet 

appetite-normal 

Bowel and bladder- regular 


General examination 

Patient was conscious coherent, cooperative

Not adequately built and  nourished

Sign of Pallor present

No signs of cyanosis clubbing lymphadenopathy ,







Fever Charting

25th and 26-10-23



Systemic examination 


C V S-S1 and S2 heard no murmurs


RS- NVBS heard 

      trachea is central


Abdomen- No tenderness, No bruit heard 


INVESTIGATIONS




Provisional diagnosis 

Viral Pyrexia with thrombocytopenia 


Treatment

25/10/23

IV fluids -NS -@100ml/hr

    Inj.Neomol 1gm IV/SOS 

Tab.PCM 650mg PO QID

Monitor vitals every 4th hrly


26/10/23

IV fluids -NS -@100ml/hr

    Inj.Neomol 1gm IV/SOS 

Tab.PCM 650mg PO


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