Fever since 4days
Generalized weakness since 4 days
Vomtings since 2 days
HOPI:-
patient was apparently asymptomatic 4 days back had his dinner and went to sleep and developed fever with body pains which on medication relieved till next day after lunch he developed vomiting non projectile food in content
From last 2 days he had vomitings 3 episodes/day and high grade fever associated with chills and rigor , bodypains, headache
He got NS1 +ve in local hospital and later got presented in casuality
On examination :
Pt is c/c/c
No signs of pallor, icterus, cyanosis, clubbing, lymphadenoapathy, edema
Vitals:
Temp:99.5f
PR: 92 bpm, regular
RR: 26 cpm
BP: 100/70 mmHg
SPO2:
AT ROOM AIR-96%
GRBS:126 mg/dl
Systemic examination :
CVS:S1,S2 heard
Apex beat:5th ICS
Resp:
BAE+(vesicular breath sounds)
Nvbs heard
Position of trachea- central
P/A: obese, tenderness absent, bowel sounds heard
Cns: NFND
Diagnosis-
Dengue fever with thrombocytopenia
Treatment given
1. IVF NS,RL @150ML/Hr
2. Inj. Pantop 40mg IV/TID
3. Inj. Zofer 4mg/IV/SOS
4. Inj.Neomol 1gm/IV/SOS
5. T.PCM 650MG/TID
7. Check for postural hypotension/bleeding manifestations 2nd hrly
8. Temp charting
9. I/O Charting
Investigations:-
1.Sr.Electrolytes
Na+. 139
K+. 4.5
Cl-. 96
2.Sr. Creatinine- 1.3
4. Hemogram
Hb-13.8
TLC-6300
N-50
L-40
E-02
B-00
M-08
PCV-39.2
MCV -79.7
MCH -28.0
RBC.-4.92
PLT-38,000
5. Blood urea-63
6. RBS-83
7. Dengue NS1 -positive
8. LDH-357
9. BGT-O+ve
10. APTT-32Sec
11. ESR-10
12. PT-15sec
Day 1
SUBJECTIVE
No fever spikes
No subjective complaints
Objective
On examination :
Pt is c/c/c
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy
Vitals:
Afebrile
PR: 44 bpm, regular
RR: 20 cpm
BP: 110/70 mmHg with NA@6ml/hr
SPO2:
AT ROOM AIR-98%
Systemic examination :
CVS:S1,S2 heard
Apex beat:5th ICS
Resp:
BAE+(vesicular breath sounds)
Nvbs heard
Position of trachea- central
P/A: soft, tenderness present at rt lumbar and rt hypochondrium
Cns: No focal deficit
Assessment-
Viral Pyrexia with thrombocytopenia with serositis
Plan
1. IVF NS,RL @150ML/HR
2. INJ. PANTOP 40MG IV/OD
3. INJ. NEOMOL 1GM IV/SOS (IF TEMP ≥101⁰F)
4. Tab.PCM 650MG PO/TID
5. Bp monitoring
6. W/F bleeding manifestations
7. Temp & I/O charting
ECG:
USG ABDOMEN
1. MILD B/L PLEURAL EFFUSION
2. MILD GALL BLADDER WALL OEDEMA(F/S/O SEROSITIS)
Day 2
SUBJECTIVE
No fever spikes
No subjective complaints
Objective
On examination :
Pt is c/c/c
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy
Vitals:
Afebrile
PR: 56 bpm, regular
RR: 20 cpm
BP: 110/70 mmHg with NA@6ml/hr
SPO2:
AT ROOM AIR-98%
Systemic examination :
CVS:S1,S2 heard
Apex beat:5th ICS
Resp:
BAE+(vesicular breath sounds)
Nvbs heard
Position of trachea- central
P/A: soft, tenderness present at rt lumbar and rt hypochondrium
Cns: No focal deficit
Assessment-
Viral Pyrexia with thrombocytopenia with serositis
Plan
1. IVF NS,RL @150ML/HR
2. INJ. PANTOP 40MG IV/OD
3. INJ. NEOMOL 1GM IV/SOS (IF TEMP ≥101⁰F)
4. Tab.PCM 650MG PO/TID
5. Bp monitoring
6. W/F bleeding manifestations
7. Temp & I/O charting
ECG:
2D -ECHO
Day 3
SUBJECTIVE
No fever spikes
No subjective complaints
Objective
On examination :
Pt is c/c/c
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy
Vitals:
Afebrile
PR: 48 bpm, regular
RR: 20 cpm
BP: 110/70 mmHg with NA@6ml/hr
SPO2:
AT ROOM AIR-98%
Systemic examination :
CVS:S1,S2 heard
Apex beat:5th ICS
Resp:
BAE+(vesicular breath sounds)
Nvbs heard
Position of trachea- central
P/A: soft, tenderness present at rt lumbar and rt hypochondrium
Cns: No focal deficit
Assessment-
Viral Pyrexia with thrombocytopenia with serositis
Plan
1. IVF NS,RL @150ML/HR
2. INJ. PANTOP 40MG IV/OD
3. INJ. NEOMOL 1GM IV/SOS (IF TEMP ≥101⁰F)
4. Tab.PCM 650MG PO/TID
5. Bp monitoring
6. W/F bleeding manifestations
7. Temp & I/O charting
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