I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and diagnosis with a treatment plan.

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

A 23 year old male came with chief complaint of Fever since 5 days.

HOPI- The patient was apparently asymptomatic 5 days ago. Then he had fever which was high grade, continuous in nature more in the night associated with chills and rigor and relieved on medication.

H/o fatigue along with fever.

No H/o headache, Muscle aches, Joint pain, rash, weight loss.

No H/o cough, abdominal pain, dysuria, diarrhoea, nausea and vomitings.

Past History- Not a known case of Diabetes, Hypertension, Asthma, Epilepsy, Tuberculosis.

Personal History- 

Appetite-Normal; Diet- Mixed; Sleep- Adequate; Bowel and Bladder- Regular, No addictions.

Family History - Not significant

On Examination-

Patient is conscious, coherent, cooperative.

No pallor , Icterus,clubbing, cyanosis , koilonychia, edema, lymphadenopathy.

VITALS 

Temp- 99°F

Bp-100/80 mm hg

Pulse- 66bpm

RR-16cpm

Systemic Examination -

Cvs-S1 S2 +

RS- Bilateral air entry  present

P/A - soft and non tender

bowel sounds present .

CNS- NAD

Investigations-



NS1 Antigen- Positive

IgG - Negative

IgM- Negative


LFT-

SGOT- 115 IU/L

SGPT- 62 IU/L

Provisional Diagnosis-

Viral Fever (Dengue NS1 Antigen-Positive)

Treatment -









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