General Medicine Case-4

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Date of admission:October 30,2021

A 43 year old male ,farmer by occupation came with c/o 

1. Fever since 4 days

  high grade , intermittent, and decreased on taking medication

  

2. Generalised body pains and weakness since 4 days

     

3. Cough since 3 days  

     Nonproductive ,constant throught the day

4.pain abdomen since 3 days 

No h/o nausea, vomitings, loose stools 

No h/o bleeding manifestations

Patient went to outside hospital with similar complaints 

He was referred to our hospital 

PAST H/O

Not a k/c/o DM, HTN, bronchial asthma , epilepsy, TB ,CAD

PERSONAL H/O 

He takes mixed diet 

Appetite - decreased

Sleep - adequate

Bowel and bladder movements- regular

Addictions - he drinks alcohol weekly once 

On general physical examination

Patient is conscious,coherent, cooperative

Moderately built and nourished 

No pallor ,icterus,clubbing,edema of feet,koilonychia, edema of feet

Vitals:-

Temperature- 101.2° F

Pr- 80 BPM

BP- 110/90 mm hg

RR- 20 cpm

Spo2- 98% at RA

Grbs- 154 mg%

Systemic examination

CVS- S1 S2 +

RS- BAE+

P/A - tenderness +

CNS- NAD by

Investigations:-

Hemogram -

Hb- 16.5 gm%

Tlc- 3100

Plt- 55,000

Pcv- 44.6

Mcv- 80.4

Provisional diagnosis 

DENGUE FEVER (ns1)WITH THROMBOCYTOPENIA

Temperature charting

1/11/21

Hemogram

A- dengue fever ns 1 postive with thrombocytopenia

? Left upper lobe consolidation (upper segment)

Treatment:

1. IV fluids ,NS, RL @ 100 ml/hr

2. Inj augmentin 1.2 gm iv tid

3. Tab.azee 500 mg od 

4. Inj pan 40 mg iv OD

5. Inj.dolo 650 mg QID

6. inj.optineuron 1amp in 100 ml ns iv OD

7. Inj.neomol 1gm iv sos (if temp >101 F)

8. Syrup.ascoryl 10 ml tid 

9. W/f bleeding manifestations

10. Monitor vitals