GENERAL MEDICINE CASE DISSCUSION
December 15, 2022
15th December 2022
CASE DISCUSSION
Hi, I am M. Praveen kumar of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.
A 17 year old male came to opd who is driver came with
CHEIF COMPLAINTS:
Blood from nasal sinuses
Fever since 4 days
Vomitings 3-4 days/day.
HISTORY OF PRESENTING ILLNESS:
Apparently a symptomatic four days back, then developed fever (continuous type) with chills and rigors
Bleeding from nose since 4 days( 2-3 times a day)
PAST HISTORY:
No cold
No vomiting
No BP
No diabetes
No asthma
No TB
PERSONAL HISTORY:
Unmarried
Mixed diet
Regular bowel movements
No allergies
Normal micturation
No addictions
FAMILY HISTORY:
No significant family
GENERAL EXAMINATION:
No pallor
No icterus
No cyanosis
No lymphadenopathy
No malnutrition
No clubbing of fingers
No oedema
FEVER CHART:-
ECG:-
1. IVF: 10NS, 10RL @75 ml/hr
2. Inj. Neomol 1 gm IV/SOS If temp goes beyond 101 f
3. Tab. Dolo 650mg po/ird
4. Inj. Tranexa 500mg IV/SOS
5. Monitor temperature
PROVISIONAL DIAGNOSIS: DENGUE FEVER
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