20 year old male with fever since 6 days, generalised weakness and bodypains 4 days ago, black colored stools since 4 days

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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 come up with diagnosis and treatment plan. 

20 year old male B Pharmcy student presented to the OPD with the complains of fever since 6 days, generalized weakness and bodypains 4 days ago , black coloured stools since 4 days

HOPI

Patient was apparently asymptomatic 6 days ago then he developed fever High grade, associated with chills and rigors, more during nights, relieved with mediation.

Generalized weakness and body pains 4 days ago now subsided 

Black coloured stools since 4 days

No history of cough, cold , shortness of breath, vomiting, loose stools , bleeding from mouth, pain abdomen.

Not a known case of HTN DM CAD thyroid or seizure disorder

Family H/o - not significant

On general physical examination -

PATIENT is conscious, coherent, cooperative

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

Vitals

PR:82/min

Supine Bp: 110/70 mmhg

Standing BP: 110/60 mmhg

Temp:97.2f

SPO2:98 ON RA

RR: 16/MIN

CVS:S1,s2 

Rs : BAE, NVBS

P/A - soft, non tender

Investigations -

Hb- 13.9

TLC-3700

PC-26000

RBS-126 MG/DL

B. UREA-16mg/dl

LFT-

TB-0. 94

SGOT-102

SGPT-71

T PROTEINS- 5.6

A/G-2 . 15

S CALCIUM-9. 9

S CREAT-0. 8

Na-139

K-4. 3

Cl-104

Ca2+- 1.15

Uric acid-4. 5

DIAGNOSIS: DENGUE FEVER WITH THROMBOCYTOPENIA

TREATMENT: IVF NS 100 ML/HR

TAB DOLO 650 MG PO/TID

INJ NEOMOL 1 GM IV/SOS ID TEMP MORE THAN 101F

USG ABDOMEN-

CHEST XRAY-

ECG-

Stool for occult blood- negative

17/02/23

20 year old male student came with the complaints of fever since 6 days, generalised weakness and body pains since 4 days, black colored stools since 4 days

S-

No fever spikes yesterday

Stools passed

Feeling better

O-

PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE,

AFEBRILE ON TOUCH

BP - supine position-120/80mmHg

Standing position - 100/60 mm Hg

PR - 84/min

Temp - 96.2F

RR - 18/min 

Spo2 - 98% @RA

Grbs-93mg/dl

Input-3500

Out put-900

CVS - S1S2 Heard & No Murmurs 

RS - BAE + ; NVBS + 

P/A - Soft & Non Tender

CNS - NAD

Investigations -

Hb- 14.2g/dl

TLC- 4000

PLC- 58000

S electrolytes-

Na-138

K-4.4

Cl-105

Ca2+ 1.10

A-

Dengue fever with thrombocytopenia 

P

IVF-NS , RL @100 ML/HR

INJ. NEOMOL 1GM IV /SOS

TAB DOLO 650MG PO/BD

STRICT INPUT OUTPUT CHARTING

MONITOR VITALS AND INFORM SOS