Case history -2

 A 22 year old female patient came to casualty with the complaint of fever from 5 days and vomiting from 5days with 2-3 episodes /day .

History of present illness:

Patient was apparently well 5 days back and then developed fever which was insidious and continuous type with vomiting of 2-3 episodes / day of non bolus , non projectile and food particles content .

HISTORY OF PRESENT ILLNESS:

Patient visited a local hospital on 15-08-21 due fever and vomiting and was given Dolo 650 three times a day and Zofer 4 twice before food.

Patient experienced chills during sleep around midnight and complaints was chest pain before vomiting.

Patient complaints of stomach ache along with fever and chills .

Patient was recommended by local hospital medical practitioner  to visit our hospital a results of diagnosis of decreased platelets count.

Patient complaints of a blood drop or 2 in urine.

PAST MEDICAL HISTORY :

No history asthma, diabetes, hypertension .

PERSONAL HISTORY :

Diet : mixed.

Appetite : normal.

Sleep: adequate.

Menstrual cycle: normal.

GENERAL - PHYSICAL EXAMINATION :

Patient was examined in well lit room.

Pallor , cyanosis and clubbing is not seen and no generalised lymphadenopathy.

VITALS: 

BP:100/80 mm Hg 

Pulse rate : 86bpm.

SpO2:98%

GRBS: 147mg/ dl 

SYSTEMIC EXAMINATION: 

CVS: 

Thrills and cardiac mummers : not heard.

Cardiac sounds : S1 and S2 are heard .

RESPIRATORY SYSTEM:

Wheeze: No.

Dyspnoea: no.

Postion of trachea : center.

Breath sounds : vesicular breath.

ABDOMEN:

Shape of abdomen : scaphoid

Tenderness: no.

Free fluid : no.

Palpable :no.

Bruits : no.

Hernial orifice:normal 

Spleen : not palpable.

Liver : not palpable .

Bowel sounds: yes.

CENTRAL NERVOUS SYSTEM:

Level of consciousness : conscious /alert.

Speech : normal.

Signs of mengieal irritation:-

A) neck stiffness : no.

B) kerning sign : no.

Investigation : 









ECG on 19-08-21



ECG on 20-08-21


PROVISIONAL DIAGNOSIS:

Dengue fever and NS1 positive .

TREATMENT:

ON  20 - 08 -21 .
1)IVF 2 NB, 2 RL @ 75ml / hr.
2) Inj. pantop 40 mg/IV /OD
3) INJ. zofer 4 mg / IV /BD
4) watch for bleeding manifestation .
5) tab. pu m 650 mg.
6) thrombocytopenia ointment for LA 

ON 21-08-21
1)IVF 2 NB, 2 RL @ 75ml / hr.
2) Inj. pantop 40 mg/IV /OD
3) INJ. zofer 4 mg / IV /BD
4) watch for bleeding manifestation .
5) tab. pu m 650 mg.
6) thrombocytopenia ointment for LA 
7)syp.mucaine gel
8)syp.ascoril

ON 22-08-21
1)IVF 2 NB, 2 RL @ 75ml / hr.
2) Inj. pantop 40 mg/IV /OD
3) INJ. zofer 4 mg / IV /BD
4) watch for bleeding manifestation .
5) tab. pu m 650 mg.
6) thrombocytopenia ointment for LA 
7)syp.mucaine gel
8)syp.ascoril.




































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