A 18year old male patient came with the chief complaints of fever since 4 days
A 18year old male patient came with the chief complaints of fever since 4 days
October 07, 2022
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A 18 year old boy,resident of vangamarthi,who had completed his intermediate came to casuality with the chief complaints of fever,body pains and weakness since 4days.
HOPI:
Patient was apparently asymptomatic 4days back and then he developed fever,body pains and weakness.Fever was intermittent,high grade fever during morning and gradually decreased by evening after taking medications,not associated with chills.H/o headache in association with fever and subsided gradually as the fever decreased.Body pains developed along with fever mostly lower limbs are painfull which was dragging type of pain and there is weakness.There is h/o abdominal pain since yesterday morning which was dragging type and localised to epigastric region.There was cracking of upper lip.
No chills,No petechia seen,no h/o diarrhea,no h/o nausea,photophobia.
Patient had h/o fever,bloody diarrhea 1month back.Then the fever was on and off,high graded and he passed loose stools 4-5 times/day for 2days.Then he gave blood sample suspecting typhoid which was positive and then he went to nalgonda and got treated.
Past history:
No similar complaints in the past.
Personal history:
Diet:Mixed
Appetite:Decreased
Sleep: Adequate
Bowel movements decreased since 3days and regular bladder movements.Today he passed stools.
No addictions.
General physical examination:
Patient is conscious, coherent, co-operative and we'll oriented to time,place,person.He is moderately built and nourished.
No signs of pallor,icterus,cyanosis,clubbing,generalised lymphedenopathy and edema.
On 7th oct,2022
PR:92 BPM
RR:18 cpm
BP:90/70mm hg
Spo2:98% at room air
GRBS:96mg%
On 8th oct,2022
Temperature:97.9F
PR:90 BPM
RR:18 cpm
BP:100/70mmhg.
Systemic examination:
CVS:S1,S2 heard no murmurs
RS: Bilateral air entry present,Normal vesicular breathe sounds heard
CNS:No neurological focal deficits.
Per abdomen:
On inspection:
Shape of the chest:flat
Flanks:
Position of umbilicus:center
Skin over the abdomen is normal
No scars,sinus,engorged veins
Movement of abdominal wall
No visible peristalsis.
No hernial orifices.
On palpation:
There is no local rise of temperature and slight tenderness on epigastric region.
All the inspectory findings are confirmed by palpation
Liver:
Non tender,soft in consistency
Spleen:
Non tender,soft in consistency
Percussion:
Liver span:
No spleenomegaly
Auscultation:
Bowel sounds heard.
No venous hum heard.
Investigations:
Hemogram:
Showing-Decreased platelet count and WBC count.
Complete urine examination (CUE)-Normal.
USG:
Gallbladder wall edema
Minimal ascites
Provisional diagnosis:
Viral pyrexia with thrombocytopenia
Dengue NS1 Positive.
Treatment:
-i.v fluids:20 normal saline and 10 ringerlactate both 100ml/hr
-Inj.NEOMOL 1mg,i.v if temp.>101F
-inj.PAN 40mg,i.v OD
-inj.OPTINEURON 1amp in 100ml NS,i.v,OD
-inj.ZOFER 4mg,i.v if required
-Tab.DOLO 650mg,per oral,TID
-Temperature charting every 4thhrly
-Moniter vitals.
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