A 21 year old male with Dengue fever Ns1 positive
Admission: 02/08/21:
A 21 year old male who is a student came to casuality with complaints of:
Fever - 1 week
Vomiting - 2 days
Passage of black stools - yesterday
Hopi:
Patient was alright 1 week back. Then he developed fever 1 week back which was subsided with medication after 3 days. Not associated with chills and rigors. Associated with headache.
Pt. had history of vomiting 2 days back one episode, which was non bilious , non projectile, and food as the content.
Patient had H/o passage of black stools yesterday morning .
Platelet count : On01/9/21 mrng- 58000, Evng-48000. On 02/09/21:mrng PLT count was 44000 . There was decreasing pattern of platelet count so he was referred to kamineni for further evaluation.
Past history:
Not k/c/o Dm, HTN, CAD, Asthma, Epilepsy, TB
Personal history:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel and bladder: regular
Addictions: No
O/E :
Pt. is conscious, coherant
well oriented to time, place , person .
No pallor, Icterus, cyanosis , clubbing , lymphadenopathy, edema .
Vitals:
Temp: 98.6°F
PR: 88/min
RR: 16 cpm
BP: 110/80mm of hg
Spo2: 98%at RA
Systemic examination:
CVS:
S1 S2 present
No murmurs
RS:
No dyspnoea, wheeze
BAE present
NVBS present
P/A: soft , non tender
CNS:
Intact
Provisional diagnosis :
Dengue fever NS1 positive
Investigations:
On 02/09/21:
Hemogram :
Hb: 13.6
TLC: 7000
PLT: 50000
Cue:
Albumin - nil
Sugars- nil
Pus cells - 2 -3
Epithelial cells - 2 -3
PT: 17
INR:1.2
APTT: 35
BGT: B +VE
Blood urea - 17
Sr. Creatinine- 0.9
Na+: 135
K+: 4.0
Cl- : 97
LFT:
TB: 0.87
DB: 0.17
AST: 56
ALT: 24
ALP: 87
TP: 5.6
A/G: 1.92
Albumin: 3.7
Chest Xray:
ECG:
On 03/09/21:
Ultrasound:
Hemogram:
Hb: 15.2
TLC: 7300
PLT: 60000
On 04/09/21:
Hemogram:
Hb: 14.3
TLC: 5200
PLT: 1.50
RTPCR: Negative
TREATMENT GIVEN:
Day0:
1. IV fluids - Ns,RL continuous infusion
2. Inj. Pan 40 mg IV od
3. Inj. Zofer 4 mg iv sos
4. Tab Dolo 650 mg po sos
5.monitor vitals
Day1:
Soap notes : Day 1:
A 21 year old male with Dengue fever Ns1 positive
S: complaints of vomitings subsided , No bleeding manifestations
O:
Afebrile
Bp - 110/70mm of Hg
PR: 76 bpm
Cvs: s1 s2 present
Rs: BAE present , NVBS
P/A : soft, non tender
A: Dengue fever Ns1 positive
P:
1.IVF - NS, RL continuous infusion
2. Inj. Pan 40 mg IV OD
3. Inj. Zofer 4 mg sos
4. Tab. Dolo 650 mg po sos
5.Monitor vitals
Day 2:
Soap notes : Day 2:
A 21 year old male with Dengue fever Ns1 positive
S: No bleeding manifestations
O:
Afebrile
Bp - 110/80mm of Hg
PR: 76 bpm
Cvs: s1 s2 present
Rs: BAE present , NVBS
P/A : soft, non tender
A: Dengue fever Ns1 positive
P:
1.IVF - NS, RL continuous infusion
2. Tab. Pan 40 mg po OD
3. Tab. MVT PO od
4. Tab. Dolo 650 mg po sos
5.Monitor vitals
Day 3:
Soap notes:
21 year old male with Dengue fever Ns1 positive
S: No bleeding manifestations
O:
Afebrile
Bp - 110/80mm of Hg
PR: 76 bpm
Cvs: s1 s2 present
Rs: BAE present , NVBS
P/A : soft, non tender
A: Dengue fever Ns1 positive
P:
1.IVF - NS, RL
2. Tab. Pan 40 mg po OD
3. Tab. MVT PO od
4. Tab. Dolo 650 mg po sos
5.Monitor vitals
Course in the hospital:
A 21 year old male came to casuality with complaints of fever, vomitings , black stools .He was referred to kamineni in view of low platelet count . His platelet count on day of admission - 44000. On 03/09/21 his platelet count was 50000. On 04/09/21 his platelet count was 1,50,000. As his platelet count is increased we planned for his discharge.
Advice at discharge :
1. Plenty of oral fluids
2. Tab pan 40 mg od for 3 days
3. Tab MVT po od
4. Tab dolo 650 mg po sos
