A 16year old male with epistaxis and fever

-

 

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment

 

 A 16 year old male patient, student, was brought to casualty with chief complaints of bleeding from nose since 4 days and fever since 4 days.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 4 days back and then he developed fever which was high grade, continuous type and associated with chills and rigors. It was relieved temporarily on medications. Patient also had bleeding from nose since 4 days, recurrent type, occurring 2-3 times per day, each episode lasting for 1 hour. Patient also has headache and body pains (back ache*) since two days. Patient has a history of nose bleeding since last 5 years but did not get treated for it.  

No history of cold, cough, vomiting. 


PAST HISTORY:

No similar complaints seen in the past. Patient is not a known case of Diabetes, Hypertension, Tuberculosis, Asthma, Epilepsy, CVD. 

FAMILY HISTORY:

No similar complaints seen in family.


PERSONAL HISTORY:

Diet is mixed, appetite is normal, sleep is adequate, bowel and bladder movements are regular. No known allergies. Non smoker and does not consume alcohol. Not any kind of medications.

 

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative. Well oriented to time, place and person. Moderately built and moderately nourished. 

There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.

Vitals --- BP: 110/70 mmHg    PR: 89 bpm    Temp: afebrile   RR: 18 cpm

 

SYSTEMIC EXAMINATION:

Cardiovascular: S1, S2 heard; no murmurs   Respiratory: NVBS + BAE+   CNS: NAD     P/A: Soft, non tender. 

PROVISIONAL DIAGNOSIS: 

Dengue fever..? 


INVESTIGATIONS:
















MANAGEMENT:

I.V fluids- NS & RL for 75ml/hr

T. pan 40mg po/od

Temp monitoring fourth hourly..

Vitals monitoring

Comments

Post a Comment

Popular posts from this blog

My experiences with general cellular and neural cellular pathology in a case based blended learning ecosystem's CBBLE

-
  Hello, I'm SAI SHREYA, a medical student from India. I'll be sharing few of my experiences in the general medicine department clinical postings, but before that I'd like to thank our mentors and HOD sir. They taught us theory and practice, gave us an inspiration to strive for perfection. As Hippocrates stated, “Wherever the art of Medicine is loved, there is also a love of Humanity.” I’m sure that all of us are truly connected through this quote. Our choice of medicine wasn’t an accident. I think that medicine is nothing without love of humanity. It is a delicate and demanding art at the end of which, when well-practiced, is renewed life and freedom from suffering and fear for our patients.  My first ever encounter with a patient was with an old woman who was agitated with pain and all of her family members were worried. She was a 59 year old who was a housewife with complaints of pain in her left pelvic bone since 2 months. It is obviously very difficult to handle
Read more

Chronic Renal failure case

-
Image
   This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment   A 82 year old male patient, resident of Choutuppal, came to casualty with chief complaints of shortness of breath since three months and chest pain, intermittent since 15 days.    History of present illness : Patient was apparently asymptomatic three months back then he developed exertional dyspnea associated with cough. Cough was productive. The sputum was wet. There is history of pedal oedema three months back which is is pitting type. There is history of chest pain, intermitten
Read more