This is an E log book to discuss our patients de identified health data shared after guardians informed consent.
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs.
This E-book also reflects my patients centered online learning portfolio and your valuable comments in comment box are most 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 and to comprehend clinical data including history, clinical finding investigations and come up with a diagnosis and treatment plan.
CHIEF COMPLAINTS
- Fever since 15 days
- Headache since 15 days
- Cough since 15 days
- Giddiness since 2 days
HISTORY OF PRESENTING ILLNESS
The 17 year old patient was apparently asymptomatic 15 days ago and then developed high grade fever which was sudden in onset, continuous and associated with chills and was relieved after taking medication. She then developed frontal headache since 15 days and dry cough since 15 days along with the complaint of chest pain.
PAST HISTORY
No H/O DM, HTN, TB, asthma, epilepsy, CAD.
PERSONAL HISTORY
DIET: Mixed
APPETITE: Normal
SLEEP: inadequate
B&B: irregular
Consumes toddy occasionally
No allergies
H/O fever in both her sister and niece
GENERAL EXAMINATION
The patient was conscious, coherent, cooperative, well oriented to time, place, person. She was moderately built and moderately nourished.
VITALS:
Temp: 98.9
PR- 85 bpm
RR- 36 cpm
BP- 90/60 mmHg
SpO2- 99%
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.
SYSTEMIC EXAMINATION
CVS - S1, S2 heard
RS: BAE +
P/A: soft, non tender
CNS: no focal neurological deficits
PROVISIONAL DIAGNOSIS:
Dengue Hemorrhagic fever
INVESTIGATIONS:
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