case -2 dengue fever

​This is 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 inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

A 30 year old patient ,farmer by occupation came to casualty with

C/o of fever , stomach pain,nausea,SOB since 2days

History of present illness:-

Age :-30yrs

Sex:-male

Occupation:-Farmer

Residence:-kethipally,nakerakel

According to my patient ,he was in usual state of health 4days back when he started abrupt high grade continuous fever documented at 97F ,associated with chills,headache, generalised body ache .

So he went for medical checkup in his locality.There the Rmp doctor suggested an injection. So After taking that injection,he was normal for that day and again he suffered from fever and stomach pain the next day. so he made an appointment for another check up in suryapet.He came to know his RBCs are low and he was suffering with dengue fever and he was on medication.

For one day after medication he was normal,and again he developed fever.(recurrent fever)

so the doctor suggested him to have a checkup here.

He was suffering from SOB and with burning micturition 2days back.

Patient used to eat rice three times a day.

But now he is having fruits and fluids (juices).

Persistant above symptoms brought patient to the hospital.

No h/o rash

            Yellowish discolouration of skin

             Altered consciousness 

             Mucosal bleeding 

Associated symptoms:-

Head ache

Pain behind neck

Burning sensation during micturition

PAST HISTORY :-

No similar complaints in the past

No hypertension

PERSONAL HISTORY:-

diet:- mixed 

loss of appetite 

Bowel and bladder movements:- regular

ADDICTIONS:-

Not a smoker 

No particular addictions 

SOCIOECONOMIC HISTORY:-

Patient lives in kethipally,ventilated house with his wife and 2 children,use tap water

FAMILY HISTORY :-

No member of family has similar disease

DRUG HISTORY:-

No H/o allergic known drugs

GENERAL EXAMINATION:-

Patient is moderately fit and nourished 

Cooperative 

Conscious 

No c/o of giddiness

No bleeding manifestations

No c/o of loose stools and vomitings

No pallor 

No icterus

No cyanosis

No generalised lymphadenopathy 

No pedal edema

VITALS:-

Temp:-97F

RR :    -

PR:-78/min

BP:-130/80mmhg

SYSTEMIC EXAMINATION:-

RS:-BAE

CVS:-S1 S2

ABDOMEN:- diffuse tenderness is seen

CNS:-NAD

Patient is conscious .His speech is normal 

Investigations:-

17/03/22

HEMOGRAM 

18/03/22 

HEMOGRAM 18/03/22 

HEMOGRAM 19/03/22

DIFFERENTIAL  DIAGNOSIS:-

Dengue fever 

Typhoid