Note: Sample only, done by a second-year visiting medical student from the USA in 1999. Just to illustrate the patient management processes.
R.J.
Patient Management Process
Pediatric Case Presentation
CASE PRESENTATION:
General Data: RO is a 16 year-old male.
CC: High-grade fever for the past 5 days.
HPI: High-grade fever that has been constant for the past 5 days. Patient also complains of headache, cold, and vomiting. Patient denies any loose bowel movement or cough. Patient sought consult yesterday at a different hospital where a CBC was performed. The CBC showed that the patient had a low platelet count with no signs of bleeding.
PE: Patient’s temperature is 39°C. Patient appears to be healthy other than the fever. The rest of the PE is normal.
CASE DISCUSSION:
Clinical Diagnosis:
1) The data from the database which can serve as cues for a clinical diagnosis in this case come mainly from the HPI (Symptoms). The result of the CBC performed previously is also a major cue.
2) Primary Clinical Diagnosis: Dengue Fever
Secondary Clinical Diagnosis: Viral Infection (Flu)
Based on the symptoms given by the patient, the results of the previous CBC, and by using pattern recognition, I concluded that the problem could be either Dengue fever or a viral infection such as the flu. The reason that I made Dengue fever my primary diagnosis over viral infection is the low platelet count, which is closely associated with Dengue fever. Consequently, I am over 90% certain of my primary diagnosis. I was able to rule out Typhoid Fever because the patient said that the fever has been constant over the past 5 days as opposed to intermittent. (Typhoid Fever presents with intermittent fever). I was also able to rule out Malaria because the patient did not complaint of any chills associated with his fever.
Paraclinical Diagnostic Procedures:
1) Primary Clinical Diagnosis: Dengue fever
Secondary Clinical Diagnosis: Viral Infection (Flu)
2) Certainty Treatment Modality
Dengue Fever 90% Fluids and rest
Viral Infection (Flu) 10% Fluids and rest
The certainty of the primary diagnosis is significant in this case, and the treatment modalities for both diagnoses are identical. Consequently, I conclude that a paraclinical diagnostic procedure is NOT NECESSARY in this case.
Treatment:
1) Primary Pretreatment Diagnosis: Dengue Fever
Secondary Pretreatment Diagnosis: Viral Infection (Flu)
2) The goals of treatment for the primary diagnosis are relief of the fever and associated discomfort, return of the patient’s platelet levels to normal, and satisfaction of the patient.
3) Treatment Modality:
Based on this data, I conclude that the best treatment in this case would to give the patient Paracetamol and instruct the patient to take one tablet every 4-6 hours only when the patient has a high grade fever. I chose medication over no medication because the patient’s chief complaint was fever, and thus my primary concern for treatment would be relief of the fever. I want to avoid bleeding, so I decided against Aspirin, which could cause GI irritation. I chose Paracetamol over Tylenol because of the faster action of Paracetamol. The end point of the treatment would be the disappearance of the fever. I would also monitor the patient with a CBC count to ensure that his platelet count had returned to normal.
3) The outcome of the proposed treatment will be evaluated depending on how successful it is in achieving the goals of treatment stated above in relation to any negative effects that may have occurred.
4) No data is available on the treatment procedures done on this patient or their outcomes.
1) The final diagnosis is Dengue fever.
2) I would advise the patient that mosquitoes, specifically the female Aeds Egypti mosquito, transmit Dengue fever. I would also tell him that it only takes one bite to receive the virus from a mosquito. Once the virus is in the blood stream, virmemia develops, and the patient’s platelets are destroyed. Finally, I would explain that the patient could prevent this kind of problem in the future by making sure to kill any mosquitoes that he saw. He could also eliminate common areas where mosquitoes like to live such as flower pots and old tires. If absolutely necessary, then the patient should have his house fumigated to kill all the mosquitoes in the house.
ROJ@11dec18