20 year old male with fever since 6 days, generalised weakness and bodypains 4 days ago, black colored stools since 4 days
M. Sri Nithya
Roll. No- 86
Unit-2
20 year old male B Pharmcy student presented to the OPD with the complains of fever since 6 days, generalized weakness and bodypains 4 days ago , black coloured stools since 4 days
HOPI
Patient was apparently asymptomatic 6 days ago then he developed fever High grade, associated with chills and rigors, more during nights, relieved with mediation.
Generalized weakness and body pains 4 days ago now subsided
Black coloured stools since 4 days
No history of cough, cold , shortness of breath, vomiting, loose stools , bleeding from mouth, pain abdomen.
Not a known case of HTN DM CAD thyroid or seizure disorder
Family H/o - not significant
On general physical examination -
PATIENT is conscious, coherent, cooperative
There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
Family history - not significant
On general examination -
PATIENT is conscious, coherent, cooperative
Well orientated to time, place and person
Vitals
PR:82/min
Supine Bp: 110/70 mmhg
Standing BP: 110/60 mmhg
Temp:97.2f
SPO2:98 ON RA
RR: 16/MIN
CVS:S1,s2
Rs : BAE, NVBS
P/A - soft, non tender
Investigations -
Hb- 13.9
TLC-3700
PC-26000
RBS-126 MG/DL
B. UREA-16mg/dl
LFT-
TB-0. 94
SGOT-102
SGPT-71
T PROTEINS- 5.6
A/G-2 . 15
S CALCIUM-9. 9
S CREAT-0. 8
Na-139
K-4. 3
Cl-104
Ca2+- 1.15
Uric acid-4. 5
DIAGNOSIS: DENGUE FEVER WITH THROMBOCYTOPENIA
TREATMENT: IVF NS 100 ML/HR
TAB DOLO 650 MG PO/TID
INJ NEOMOL 1 GM IV/SOS ID TEMP MORE THAN 101F
USG ABDOMEN-
Stool for occult blood- negative
17/02/23
AMC-BED NO. 1
UNIT-2
DOA- 16/2/23
20 year old male student came with the complaints of fever since 6 days, generalised weakness and body pains since 4 days, black colored stools since 4 days
S-
No fever spikes yesterday
Stools passed
Feeling better
O-
PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE,
AFEBRILE ON TOUCH
BP - supine position-120/80mmHg
Standing position - 100/60 mm Hg
PR - 84/min
Temp - 96.2F
RR - 18/min
Spo2 - 98% @RA
Grbs-93mg/dl
Input-3500
Out put-900
CVS - S1S2 Heard & No Murmurs
RS - BAE + ; NVBS +
P/A - Soft & Non Tender
CNS - NAD
Investigations -
Hb- 14.2g/dl
TLC- 4000
PLC- 58000
S electrolytes-
Na-138
K-4.4
Cl-105
Ca2+ 1.10
A-
Dengue fever with thrombocytopenia
P
IVF-NS , RL @100 ML/HR
INJ. NEOMOL 1GM IV /SOS
TAB DOLO 650MG PO/BD
STRICT INPUT OUTPUT CHARTING
MONITOR VITALS AND INFORM SOS
18/02/23
AMC-BED NO. 1
UNIT-2
DOA- 16/2/23
20 year old male student came with the complaints of fever since 6 days, generalised weakness and body pains since 4 days, black colored stools since 4 days
S-
No fever spikes yesterday
Stools passed yesterday night
No bleeding manifestations
O-
PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE,
AFEBRILE ON TOUCH
BP - supine position-120/70mmHg
Standing position - 120/80 mm Hg
PR - 80/min
Temp - 97.4F
RR - 16/min
Spo2 - 98% @RA
Grbs-101mg/dl
Input-4200
Out put-1250
CVS - S1S2 Heard & No Murmurs
RS - BAE + ; NVBS +
P/A - Soft & Non Tender
CNS - NAD
Investigations -
Hb- 14.1g/dl
TLC- 3900
PLC- 1.10
Neutrophils -18
Lymphocytes -73
Pcv- 41. 8
A-
Dengue fever with thrombocytopenia
P
IVF-NS , RL @100 ML/HR
INJ. NEOMOL 1GM IV /SOS if temp>101F
TAB DOLO 650MG PO/BD
STRICT INPUT OUTPUT CHARTING
MONITOR VITALS AND INFORM SOS
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