16 yr old male

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 box.

Icu bed no 5
16 yr old male 
Hopi:
Pt was apparently asymptomatic 4 days ago then he developed fever with chills, generalized weakness and 4 episodes of vomiting since the previous day, which was nonbilious and non projectile. Then yesterday morning, he also saw that he had black colored stools and brownish urine. He also complained of  abdominal tightness.
Not a k/c/o of htn, dm, tb, asthma, cad.
Investigations done were 

21/08/22
 


SDP done on 21/08/22 at 9:50 pm

  

22/08/22

S : no fresh complaints 

O
Pt. Is concious, coherent, cooperative 
PR 82 bpm
RR 18cpm
TEMP : 98.4F
BP 110/70 mmHg
RS: BAE+, clear 
CVS: S1 S2 + , NO added sounds 
P/A: soft and non tender. 
CNS : NAD 

A: fever with thrombocytopenia 

Plan of treatment 
IV fluids 2NS, 2RL @75ml/hr
Inj. Neomol 1gm IV SOS
Temp. Charting 4th hourly
Monitor vitals and inform sos
Provisional diagnosis: fever with thrombocytopenia.

Discharge summary 

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