This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

 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, come up with a diagnosis and treatment plan.

Chief complaints:

A 17 yr old girl from Suryapet came with the chief complaints of fever,weakness and pain in the legs.

History of presenting illness:

Patient was apparently asymptomatic 5 days back then she developed fever which is of high grade not associated with chills and rigor and fever is continuous and relieved on taking medication and developed generalised weakness and dragging type of pain of both lower limbs since 5 days.

No h/o shortness of breath, palpitations and chestpain

No h/o pain in the abdomen,vomiting,loose stools

No h/o cough,cold

No h/o burning micturition and hematuria.

History of past illness:

Not a known case of diabetes and hypertension.

Personal history:

Diet:mixed

Appetite:normal

Bowels:normal

Micturiton:normal

Allergies:absent

Addictions:none

Sleep:normal

Family history:

No h/o similar complaints in family.

General examination:

Patient is c/c/c well oriented to time,place,person.

Moderately built,moderate nourishment.

Vitals:

Pulse rate:74 beats/min

Respiratory rate:14/min

BP:120/70 mm/hg

Temperature:Afebrile

Physical examination:

Pallor:absent

Icterus:absent

Cyanosis:absent

Clubbing:absent

Generalised lymphadenopathy:absent

Edema of feet:absent 

Systemic examination:

CVS:

S1 S2 Heard.

No cardiac murmers

Respiratory system:-

Dyspnoea:absent

Wheezing:absent

B/L air entry present

Vesicular breath sounds heard

Abdomen:

Scaphoid shaped abdomen

No tenderness

No palpable mass

No hernial orifices.

CNS:

Conscious

Speech:normal

Sensory system is normal

Motor system is normal

Investigations:

On 2/09/2022.

On 3/09/2022.

On 4/09/2022

TPR graph sheet.

ECG.

Provisional diagnosis:

Dengue with Thrombocytopenia.

Treatment:

I.V FLUIDS NSRL 100ML/HOUR.

Inj.NEOMOL 1 gm/i.v.

Inj.PAN 40MG/i v/o.d.

Inj.ZOFER 4 mg/i v.

Tab.PCM 650 mg.

Monitor vitals.