Viral pyrexia? Thrombocytopenia?

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


" I’ve 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 "

Cheif complaints:

Fever since 4 days

C/o cold since 2 days

C/o cough since 2days


Patient was apparently asymptomatic 4 days back and developed fever which was insidious in onset,


 not associated with any sputum 

No c/o pain abdomen,burning mitcturation,constipation 

Not a k/c/o asthma htn dm 


General examination:

Vitals:

Bp:110/70

Pr:82bpm 

Rr :16cpm 

Temp :97.3


No pallor icterus clubbing cyanosis 

Cervical lymphadenopathy +

Oral petechiae +


Per abdominal examination:

Patient exposed from nipple to mid thigh and examined in supine position

INSPECTION: 

  • Shape:scaphoid

  • Umbilicus: central

  • Skin over the abdomen is normal

  • No visible peristalsis, 

  • No Visible superficial vessels

  • External genitalia normal


    Palpation:
    On superficial Palpation
    All inspectory findings are confirmed
    No local rise of temperature
    Tenderness+
    No Rebound tenderness

    • No guarding,rigidity

      No organomegaly

      Percussion:

      Shifting dullness nil

      fluid thrill nil

      Auscultation:

      Bowel sounds heard

      Cns: no neurological deficits

      Rs : bilateral vesicular breath sounds heard

      Cvs s-s2 heard

Investigations:










Rx:

Iv fluilds 

Tab doxycycline 100mg po bd 

INJ neomol 1gm iv sos 

Tab pcm 650 mg po tid 

Syp Lactulose



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