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I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
CASE DISCUSSION:
A 22 year old male came with complaints of Fever with chills,Headache ,Lower back pain,Generalised body pains,Cough with expectoration since 5 days.
HOPI:
Patient was apparently asymptomatic 5days back and then developed fever associated with chills (high grade) intermittent with evening rise in temperature associated with headache(frontal) and cough which is productive (white colour) and generalised body pains.
PAST HISTORY:
Not a K/C/O DM, HTN, TB,EPILEPSY, ASTHMA
PERSONAL HISTORY:
He is Single and Car driver by occupation.
He consumes
- Mixed diet
- sleep is adequate
- Appetite normal
- bowel and bladder movements are regular
- He used to Consume Alcohol occasionally.
FAMILY HISTORY: no similar complaints in the family.
GENERAL EXAMINATION:
Patient is conscious , coherent and cooperative and well oriented to time place
and person,
Moderately built and moderately nourished.
VITALS:
BP: 120/80mmhg
PR: 84
RR: 18
Temp: 99.5f
SYSTEMIC EXAMINATION:
RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: not tender
CNS: NAD
PROVISIONAL DIAGNOSIS: DENGUE FEVER
INVESTIGATIONS:
26/8/22
27/08/2022
28/08/22
TREATMENT:
1. IV fluids 2 NS 2 RL @75ml/hr
2. Inj.Neomol 1gm/iv/sos (if temp>102f)
3. Tab.DOLO 650mg/PO/SOS
4. SYP. Ascoril-LS 15ml/PO/TID
5. Temp charting 4th hrly
6. Monitor vitals inform SOS
27/08/2022
Day 2
S: fever with chills, backpain, headache,cough with expectoration since 5 days.
O: pt is conscious, coherent,cooperative.
BP: 110/80mmhg
PR: 84
RR: 18
Temp: 99f
RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: not tender
CNS:NAD
A: DENGUE FEVER
P:
1. IV fluids 2 NS 2 RL @75ml/hr
2. Inj.Neomol 1gm/iv/sos (if temp>102f)
3. Tab.DOLO 650mg/PO/SOS
4. SYP. Ascoril-LS 15ml/PO/TID
5. Temp charting 4th hrly
6. Monitor vitals inform SOS
28/08/22
Day 3
S: fever with chills, backpain, headache,cough with expectoration since 5days.
Presently severe back pain since night
O: pt is conscious, coherent,cooperative.
BP: 120/80mmhg
PR: 96
RR: 20
Temp: 99f
RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: not tender
CNS:NAD
A: DENGUE FEVER
P:
1. IV fluids 2 NS 2 RL @75ml/hr
2. Inj.Neomol 1gm/iv/sos (if temp>102f)
3. Tab.DOLO 650mg/PO/SOS
4. SYP. Ascoril-LS 15ml/PO/TID
5. Temp charting 4th hrly
6. Monitor vitals inform SOS
7.Tab.Ultracet 1/2 QID
29/08/22
Day 4
S: fever with chills, backpain, headache,cough with expectoration since 5days.
back pain relieved
O: pt is conscious, coherent,cooperative.
BP: 120/80mmhg
PR: 100
RR: 20
Temp: Afebrile
RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: not tender
CNS:NAD
A: DENGUE FEVER
P:
1. IV fluids 2 NS 2 RL @75ml/hr
2. Inj.Neomol 1gm/iv/sos (if temp>102f)
3. Tab.DOLO 650mg/PO/SOS
4. SYP. Ascoril-LS 15ml/PO/TID
5. Temp charting 4th hrly
6. Monitor vitals inform SOS
7. Tab.Ultracet 1/2 QID
DISCHARGED ON 29/08/2022 as the symptoms subsided and Rapid Dengue was non-reactive.
ADVICE AT DISCHARGE:
1.Tab.Dolo 650mg PO SOS
2.Tab.MVT OD for 10 days
3.Plenty of fluids to be taken
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