A 38 yr old male with fever ,cold cough, generalized weakness,headache,SOB

 Hello, I am Y.N.Indu Vaishnavi,a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio

This is a case of 38 year old male came with cheif complaints of 

1.Fever with chills
2.cold
3.Cough
4.Generalized weakness
5.Head ache(frontal region)
6.SOB grade 2
7. Loose stools


HOPI:-
Patient was apparently asymptomatic 4days back. Then he developed fever which was high grade fever with chills which eas intermittent relieved by medication associated with cold,cough which is dry in nature and generalized weakness.
Since 1 day he has complaints og loose stools of 5 episodes which is watery and non blood stained and non mucoid.No complaints of pian abdomen or vomitings.

PAST HISTORY:-
Not a known case of HTN/DM,
/Thyroid disorder/TB/Asthma/CAD

PERSONAL  HISTORY:-

DIET- Mixed

APPETITE- Normal

SLEEP- Adequate 

BOWEL AND BLADDER MOVEMENTS - regular 

ADDICTIONS -none 


FAMILY HISTORY 

Not significant 


GENRAL EXAMINATION

The patient is coherent, conscious,cooperative well oriented to time place and person 

He is moderately built and nourished 

PALLOR -absent 

ICTERUS -absent 

CYANOSIS -absent 

CLUBBING -absent 

EDEMA -absent 

LYMPHADENOPATHY -absent 


VITALS :-

TEMP-98.9f

PR-110bpm

RR -22cpm

BP-110/80

Spo2-98%


SYSTEMIC EXAMINATION 

CVS-S1S2 heard 

CNS-Higher motor functions intact 

PA-Soft and non tender 

RS- BAE+


DIAGNOSIS-

VIRAL PYREXIA WITH THROMBOCYTOPENIA DENGUE NS1 +


INVESTIGATIONS.-

6/9/22












7/9/22














8/9/22


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