Dengue fever
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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 in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan
**CASE OF 16 YEAR OLD MALE PATIENT
WITH DENGUE FEVER.
A 16 year old male patient came to casuality on 26 th October with cheif complaints of fever with chills since 5 days.
** Cheif complaints
Weakness since 8days
Fever since 5days
Abdominal pain since 2days
Vomiting since 2days
**History of presenting illness
Patient was apparently asymptomatic 8 days ago then he developed weakness for 3 days ,on third day he went to swim in near by lake despite of his weakness after that day he developed fever with chills without rigors and releived by medication and
abdominal pain ( intermittent and squeezing type) since 2 days not associated with any distention, diarrhoea
Vomiting since 2 days after meals, non bilious,non projectile
Leg pains were present two days back for three days
And he was complaining of chest tightness while eating ,no history of breathlessness
No history of blood in stools or black stools
**Past history:-
History of fever for 7 days at age of 14 and diagnosed as typhoid used medication for 7 days
No history of epilepsy
No history diabetes , hypertension, thyroid
No significant surgical history
**Personal history:-
Diet-mixed
Appetite- normal but unable to eat due to chest tightness
Bowel and bladder Movements- patient complains of burning micturition since two days , narmal bowel movements ,no h/o constipation ,melena ,blood in stools
No know allergies
No history of addictions
**Family history
His father had fever since one day
No other significant family history
GENERAL EXAMINATION:-
Patient is conscious, coherent, cooperative
Moderately built and moderately nourished
pallor absent
Icterus absent
cyanosis absent
clubbing absent
lymphadenopathy absent
edema absent
**Vitals:-
Pulse- 73 BPM
Temp- afebrile
Rr : 20
Spo2-98
Blood pressure -120/80
**Systemic examination
CVS: S1 and S2 are heard ,no murmurs are heard
Respiratory system:-
Position of trachea is central
Vesicular breath sounds are heard
Abdominal examination:-
Shape of abdomen is scaphoid
No tenderness
No palpable masses
CNS:-
Conscious,
Narmal speech
No neck stiffness
All reflexes are intact
*Provisional diagnosis:- Dengue
ULTRASOUND REPORT
Liver, spleen, pancreas are normal
Mild ascites seen in USG
Gall bladder wall is edematous
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