CASE DISCUSSION ON 16 YEAR OLD MALE WITH DENGUE

 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 a series of inputs from an available global online community of experts with an aim to solve those patient's 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 in the comment box is welcome.

Neha Tipparaju 

9th Semester, Roll no. 100 

Case of 16 year old male with Dengue fever 

I've been given this case, in an attempt to understand the topic of "patient clinical data analysis" and to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations as well as to come up with a diagnosis and treatment plan.

All the information was obtained from the patient's relative, under the guidance of Dr. Rakesh Biswas sir.

My view of the case:

Chief complaints:

A 16 year old male, resident of Nalgonda, was bought to the casuality, complaining of:

Fever since 5 days 

Pain abdomen since 5 days 

2 episodes of vomitings 

His vitals on admission in the casuality (on 26/10/21) were:

Heart rate: 103 BPM 

Respiratory rate: 18 cpm 

Blood pressure: 90/50 mmHg 

SPO2: 98% Room air 

Presently, the patient is complaining of itching all over the body, especially on the palms and soles.

History of presenting illness:

Patient was apparently assymptomatic 5 days back when he developed a fever which was incidious in onset, intermittent, low grade and not associated with any headache, diarrhoea, chills or rigour.

He also complained of pain abdomen, diffusely present in all quadrants, intermittent, squeezing type of pain, not radiating or migrating and relieving on medication.

On the evening of 26th, the patient had 2 episodes of vomiting which was non bilious, non blood stained, non projectile. It was preceded by nausea.

The patient did not complain of any burning micturition, rash, hematemesis, melaena, epistaxia, hemoptysis or hematuria.

Patient has developed an itching sensation all over the body, which is not relieving on medication.

Past History:

No similar complaints in the past.

He is not a k/c/o Diabetes mellitus, hypertension, tuberculosis, asthma, heart disease

No relevant surgical or drug history 

Personal history:

Diet is mixed 

Appetite is normal 

Bowel and bladder are regular 

Sleep is adequate 

No known allergies or addictions

Family history:

Not significant 

General Examination:

The patient is examined in the sitting position, in a well lit room after taking informed consent.

He is conscious, coherent, cooperative, well oriented to time, place and person.

Moderately built and nourished. On examination for signs:

No pallor

No icterus 

No cyanosis

No clubbing

No koilonychia 

No lymphadenopathy

No generalized edema 

No pedal edema was observed.

JVP was not seen to be raised.

Vitals:

BP: 100/70 mm of Hg 

PR: 64 bpm 

Respiratory Rate: 21 cpm

Tempature: 98.7°F

Systemic examination:

CVS: S1, S2 heart sounds heard, no murmer  

Respiratory system: Bilateral air entry present 

 CNS: Intact 

Abdomen: Soft and non tender, Bowel sounds heard no organomegaly 

Investigations: (27/10)

As of 28/10

His platelet counts increased and the itching has reduced 

As 29/10

Patient is complaining of swelling and pain in the left gluteal region since 1 week.

No h/o trauma

H/o I.M injection give one week back

(Details of what was given was not clear)

On examination, it was a 6×5 cm abscess which was tender.

As of 30/10

General well being was assessed

Abscess spontaneously resolved and patient was discharged.