A 21 year old female patient with fever , chills and body pain

Hi, I am U.Sravani, 3rd semester medical student. This is our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. This elog also reflects my patient centered online learning portfolio.
 A 21 yr old female housewife by occupation came with 


Chief complaints :
1. Fever since 4 days
2. Vomiting 2- 3 episodes/day since 3 days
3. Body pains since 4 days

HOPI :
Patient was apparently asymptomatic 4 days back then she developed fever, more in the evening associated with chills relieved with medication. Then patient started having vomiting since 3 days 2-3 episodes per day with food as contents, non-projectile, non-bilious and not stained with blood. Patient had body pains since 3 days which was more in lower back, hands and legs which was not relieved with medication.
No h/o headache
No h/o diarrhea, vomiting.


Past History :
Not a k/c/o DM,htn,tb,asthma,epilepsy 

On presentation:
Pt conscious,coherent,cooperative,well oriented to time place and person.
General Examination : No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema
PHYSICAL EXAMINATION 

GENERAL EXAMINATION 

Well built

Well nourished

No pallor

No icterus

No cyanosis

No clubbing of fingers

No pedal oedema

No lymphadenopathy

Mild dehydration

VITALS

BP- 110/70mm Hg
PR- 94bpm
RR- 20 cpm
Temp - 98.6
GRBS- 71 mg/dl

Systemic Examination : 

CVS- S1 S2 heard
RS- BAE present
PA - Soft, non-tender
CNS- NAD
Reflexes -
                        Right side Left side
Biceps - ++ ++
Triceps- ++ ++
Supinator- ++ ++       
Ankle - ++ ++
KNEE- ++ ++

INVESTIGATIONS :

1. Hemogram (12-09-22)

2. RBS

3. Serum Creatinine 

4. Serum electrolytes 




5. Chest X ray

6. Hemogram (11-09-22)


7. M. P. Strip test




PROVISIONAL DIAGNOSIS :
DENGUE (NS1 POSITIVE WITH THROMBOCYTOPENIA)


TREATMENT :
1)INJ. NEOMAL 1gm IV if temp > 102°F
2) TAB DOLO 650mg PO/ TID
3) INJ PAN 40mg IV / OD
4) INJ ZOFER 4 mg TID/ SOS
5) IVF 10 RL @ 100 ml/ hr
6) TEMP AND VITALS MONITORING 4th hrly


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