Case of dengue
19/M with fever and body pain
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Cheif Complaints :
A 19yr old male patient came to the opd with chief complaints of fever Since 1 week.
HOPI:-
Patient was Apparently asymptomatic 1 week back then he developed fever with chills which is high grade ,sudden in onset & associated with body pains .Relieved on medication.
2 days back he was taken to outside hospital there his platelet count was 1,29,000 cells/cumm, yesterday they were 1,32,000cells/cumm.Today they were 98,000cells/ cumm.
No h/o Loose stools, vomitings,
No h/o Hematuria, dark stools.
No h/o pain abdomen,giddiness.
PAST HISTORY:-
Not a k/c/o HTN,DM, Thyroid, Epilepsy.
PERSONAL HISTORY:-
diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movement- normal
Addictions:-
Patient doesn’t smoke
Non alcoholic
Drug history:-
No relevent drug history
GENERAL EXAMINATION:-
Patient was conscious, coherent, cooperative,well oriented to time place and person.
Moderately built & moderately nourished.
No pallor,
Icterus,
cyanosis,
Generalised lymphadenopathy,
clubbing.
Vitals:-
BP -90/60mmhg
PR -84
RR -14cpm
Spo2 -99
Temp:-99.5 F
Systemic examinations:-
CVS- S1 S2 +
CNS- NAD
R/S - BAE +
Chest - bilaterally symmetrical
No drooping of shoulders.
Trachea - central in position
P/A - soft,nontender .
PROVISIONAL DIAGNOSIS:-
DENGUE( NS1 +, IgM+) WITH THROMBOCYTOPENIA.
TREATMENT:-
1) Iv fluids NS @ 100ml/hr
2) Tab DOLO 650 mg Po/TID
3) INJ PAN 40 mg IV/OD
4) INJ NEOMOL IV/ SOS( IF TEMP >101 F
5) INJ ZOFER 4mg IV/SOS
6) BP AND TEMP MONITERING
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