A 14 year old male with fever and cough

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 14 YEAR OLD MALE WITH FEVER AND COUGH.

A 14year old male came  to casualty with chief complaints of 
fever since 4 days. C/o cough since 4days

Patient was apparently asymptomatic 4 days back then he developed fever which is of insidious in onset, intermittent and is of high grade fever,a/w chills and body pains.
C/O cough since 4 days which is associated with sputum . 
Patient has h/o 1episode of vomiting 2days back which is non bilious,non projectile.
No h/o pedal oedema,decreased urine output,sob,palpitations.
No h/o chest pain,abdominal pain

PAST HISTORY:
Not a k/c/o HTN,DM, CAD, asthma, TB, epilepsy.


PERSONAL HISTORY:
Patient has mixed diet with normal appetite and adequate sleep. 
he has normal bowel movements and bladder filling. 
No addictions. 

No significant family history or allergic history. 

GENERAL EXAMNATION:
Patient is c/c/c with moderate built and moderate nourishment. 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema. 
VITALS:
BP: 100/80 MMHG, 
PR: 90bpm 
Temp: 98.2°F, 
RR: 22 CPM, 
SPO2: 98% 

RS: BAE+,NVBS

CVS: S1 ans S2 heard. No murmurs. 
P/A: soft and non-tender. 
CNS: No focal deformities. 

INVESTIGATIONS:
1) HEMOGRAM : 
Hb: 12.6
TLC: 4,200
PCV: 37.6
PLT: 3.41

2) LFT:
TB: 0.76
DB: 0.25
SGOT: 51
SGPT: 21
AP: 519
TP: 6.3
A: 2.2
A/G: 0.55

3)CUE
Alb:trace
Sug:nill
Ec:2-3
Pc:2-3
RBC:bill



4)BLOOD UREA:34

 5)SERUM ELECTROLYTES:
Na+:136
K+:4.1
Cl-:102

6) serlogy - negative
Dengue- positive,IgG,IgM negative

7)CXR-

Fever charting- 

Ecg-


PROVISIONAL DIAGNOSIS:DENGUE FEVER NS1positive

Treatment given- 
IV FLUIDS-NS,RL @ 75 ml/hr
Tab.augmentin 625 mg po/bd
Tab.dolo 650 mg po/tid
Inj.pan 40 mg/po/od
Inj.optineuron 1 amp in 100 ml NS IV od
Syr.grillinctus bm 100 ml/po/tid
Plenty of oral fluids
Inj.neomol 1 g/IV/sos only if temperature greater than 101°F
Strict i/o monitoring
Watch for bleeding manifestations and postural drop.


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