A 23 year old with fever and abdominal pain

I Nandini, 3rd semester student.This is an online E log book 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 series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome

A 23year old male resident of nakerekal came with the cheif complaints of fever since one week and abdominal pain since one week

HOPI:
patient was apparently asymptomatic one week back and then he developed fever which was low grade increasing in the night associated with abdominal pain more in the umbilical region and right hypochondrial region aggravated on walking and doing work and decreased on rest,  2 episodes of vomitings on 1st day , subconjuctival hemorrhage and  erythematous rash on the inner thighs on the 2nd day  and there is history of constipation for 2days so admitted in the local hospital and diagnosed as dengue positive, rash subscied after 3 days, no cough and cold 

 PAST HISTORY:
No history of diabetes, hypertension, epilepsy
Tb,
H/o of poilo to the right leg after one year of birth
Family history: not significant

PERSONAL HISTORY:
Diet-mixed 
Appetite-normal 
Sleep-adequate
Bowel and bladder movements-regular Addictons-none 


GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative. moderately built and nourished.
Pallor-absent
Icterus-absent
Clubbing-absent 
Cyanosis-absent 
Generalised lymphadenopathy-absent 
Pedal edema-absent 



Vitals:Temperature- 99.3F
Pulse rate-98bpm
Respiratory rate- 18cpm
Blood pressure -140/90
Spo2- 98%at room air
SYSTEMIC EXAMINATION:

Cardiovascular system:
S1 and S2 heard no murmurs heard 

Central nervous system: 
No focal neurological deficit, cranial nerve
 intactCentral nervous system:
Patient is concious coherent.
Higher mental status-
Cranial nerves- intact
Motor 
   Tone- normal 

   Power- normal

Cerebellar functions-normal 

Respiratory system:Bilateral air entry-present ,Normal vesicular breath sounds-heard

Abdominal examination: soft and non tender, No Hepatomegaly, spleen is not palpable

INVESTIGATIONS

PROVINCIAL DIAGNOSIS:
dengue hemorhagic fever associated with hepatitis
Treatment:
   Platelet transfusion was done
   IVF NS and RL 100/hr
   Inj doxycycline 100mg/N/BD
   INJ.PAN 40MG/PO/OD
DOLO650 /PO/TID
  INJ NEOMOL 1gm/N/SOS
   T.CITRIZINE 10mg
   T.GRILLINCTUS 10ml/PO/TID

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