GENERAL MEDICINE: VIRAL PYREXIA

 Hi, I am A satyanarayana 3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

               A male patient of 23 yrs old from miryalaguda resident came to op with chief complaints of fever since 4days and abdominal pain since 1 day

CHIEF COMPLAINTS

Patient came to casuality with fever since 4 days and abdominal pain since 1 day 

History of present illness

Patient was apparantly asymptomatic since 4 days ago then he got fever on and off 

He went to a private hospital in miryalaguda and got tested with platelets report 116000 and they said he got dengue symptoms

       On next day his platelets were reduced to 45000 ,then that pvt hospital staff suggested to go to kamineni... Then nxt day his platelets were reduced to 31000 

History of past illness

No history of past illness

FAMILY HISTORY:

No family history

Treatment history

No diabetes

No hypertension

No tuberculosis

No asthma 

No CAD

No blood transfusions

PERSONAL HISTORY:

Diet :normal 

Apetite: normal 

Micturition: normal

Occassionally alcohol intake 3 yrs back 

Bowels : normal 

GENERAL EXAMINATION:

No pallor 

No icterus 

No cyanosis 

No clubbing of fingers

No lymphadenopathy  

there is no poedal odema 

SYSTEMIC EXAMINATION:

Cardiovascular system 

S1 and s2 sounds heard 

No murmurs 

No thrills

Respiratory system 

Trachea central in position 

Breath sounds vesicular 

No wheezing sounds heard

Central nervous sysytem 

Tenderness in abdominal region

The patient is conscious 

Speech: normal

Reflexes :present

Provisional diagnosis

Viral pyrexia Dengue Igm positive

Treatment

Tab Dolo 650 mg

Tab Dox 100 mg

Tab pantop 40 mg 

IVF ns 100 ml per hour

ULTRA SOUND REPORT :

FEVER CHART

ANATOMICAL LOCATION OF PROBLEM

WHAT ARE WE DOING WITH THIS?

The patient is undergoing treatment with

Tab dolo

Tab pantop

TabDox