fever projr dengue 202239576 25/f
Diagnosis
VIRAL PYREXIA WITH DENGUE IGM POSITIVE (RECOVERED)
UTI
Case History and Clinical Findings
PATIENT CAME WITH CHIEF COMPLAINTS OF
- FEVER (HIGH GRADE) SINCE 9 DAYS
-BURNING MICTURITION SINCE 9 DAYS
-NAUSEA AND VOMITINGS SINCE 9DAYS
-HEADACHE(DIFFUSE) WITH NECK PAIN SINCE 9DAYS
-BODY PAINS SINCE 9DAYS
-DRY COUGH (INTERMITTENT) SINCE9DAYS
HISTORY OF PRSENT ILLNESS
PATIENT WAS APPARANTELY ASYMPTOMATIC9 DAYS AGO.THEN SHE DEVELOPPED FEVER (HIGH GRADE) ASSOCIATED WITH CHILLS AND RIGORS,INCREASE IN TEMPERATURE AT NIGHT AND RELIEVED ON TAKING MEDICATION AND REVERTS BACK.SHE ALSO DEVELOPPED NAUSEA VOMITING 9 DAYS BACK.SHE ALSO DEVELOPPED HEADACHE(DIFFUSE) ASSOCIATED WITH NECKPAIN SINCE 9 DAYS.SHE HAVE BODY PAINS FROM 9DAYS.SHE HAD DRY COUGH(INTERMITTENT) FROM 9DAYS
BRIEF COURSE IN HOSPITAL
24 YEAR OLD FEMALE CAME TO THE CASUALTY ON 19/09/2022 WITH CHIEF COMPLAINTS OF
-FEVER (HIGH GRADE) SINCE 9 DAYS.ASSOCIATED WITH CHILLS AND RIGORS.RAISE IN TEMPERATURE SEEN AT NIGHT AND RELIEVED ON MEDICATION AND REVERTS ACK.
-BODY PAINS,HEADACHE ASSOCIATED WITH NECK PAIN SINCE 9 DAYS
-NAUSEA AND VOMITINGS SINCE 9 DAYS
-BURNING MICTURITION SINCE 9 DAYS
-DRY COUGH(INTERMITTENT) SINCE 9 DAYS
SHE WAS TESTED DENGUE IGM POSITIVE ON 14/09/2022.REQUIRED INVESTIGATIONS WEWRE DONE AND PATIENT IS SHIFTED TO AMC.INITIALLY SHE WAS ON IV FLIDS.TAB.DOXYCYCLINE WAS GIVEN FOR 4DAYS.
PAST HISTORY
-TESTED DENGUE IGM POSITIVE ON14/09/2022
-N/K/C/O DM,HTN,ASTHMA,EPILEPSY,TB,THYROID DISORDERS,CVA,CAD
GENERAL EXAMINATION
PALLOR-ABSENT
ICTERUS-ABSENT
CYANOSIS-ABSENT
CLUBBING-ABSENT
LYMPHADENOPATHY-ABSENT
EDEMA-ABSENT
VITALS
BP-100/60 mmHg
PR-132BPM
TEMP-102.2F
SPO2-99% at RA
GRBS-154 MG/DL
SYSTEMIC EXAMINATION
=>CVS-S1S2+
NO THRILLS
NO MURMURS
=>R/S-BAE+
NVBS HEARD
TRACHEA-CENTRAL
NO WHEEZE
NO DYSPNOEA
NO ADVENTITIOUS SOUNDS HEARD
=>P/A-SOFT AND TENDERNESS SEEN IN RIGHT LUMBAR REGION
SHAPE OF ABDOMEN-SCAPHOID
NO FREE FLUID
NO PALPABLE MASS
HERNIAL ORIFICES-NORMAL
NO ORGANOMEGALY
=>CNS-PATIENT IS CONSCIOUS COHERENT AND COOPERATIVE
SPEECH-NORMAL
NO SIGNS OF MENINGEAL IRRITATION
NFND
Investigation
19/09/2022
=>CBP
HB-10.7GM/DL
TLC-9600 CELLS/CUMM
N-55
L-35
M-8
RBC-3.84 MILLIONS/CUMM
PLATELETS-1.85 LAKHS/CUMM
=>RBS-130 MG/DL
=>USG ABDOMEN-MILD HEPATOSPLENOMEGALY
RIGHT KIDNEY-11.1#4CM-CMD+
LEFT KIDNEY-11.7#5CM-CMD+
UB-PARTIALLY DISTENDED
GB-PARTIALLY DISTENDED
=>CRP-1.2 MG/DL
=>BLOOD CULTURE AND SENSITIVITY-INSIGNIFICANT GROWTH
=>URINE CULTURE AND SENSITIVITY-INSIGNIFICANT GROWTH
20/09/2022
=>HEMOGRAM
HB-10.5 GM/DL
TLC-6600 CELLS/CUMM
N-64
L-27
M-9
E-0
PCV-30.8
RBC-3.74 MILLION/CUMM
PLATELET COUNT-1.51 LAKHS/CUMM
21/09/2022
=>HEMOGRAM
HB-10.7 GM/DL
TLC-7200 CELLS/CUMM
N-56
L-37
M-4
E-3
PCV-32.3
RBC-3.83 MILLIONS/CUMM
PLATELET COUNT-1.71 LAKHS/CUMM
22/09/2022
=>HEMOGRAM
HB-11.3 GM/DL
TLC-8200 CELLS/CUMM
N-50
L-40
M-7
E-3
PCV-34.7
RBC-4.07 MILLIONS/CUMM
PLATELET COUNT-2.03 LAKHS/CUMM
Treatment Given(Enter only Generic Name)
1)TAB.ZOFER 4MG PO/SOS
2)TAB.DOXYCYCLINE 100MG PO/BD
3)TAB.PCM 650MG PO/QID
4)TAB.RIBOFLAVIN 10MG PO/BD
5)SYP.CITRALKA 10ML IN 1GLASS OF WATER PO/TID
Advice at Discharge
1)TAB.DOXYCYCLINE 100MG TWICE DAILY AT 8AM AND AT 8PM
2)TAB.PAN 40MG ONCE DAILY AT 8AM (BEFORE BREAKFAST)
3)TAB.RIBOFLAVIN 10MG TWICE DAILY AT 8AM AND 8PM
4)TAB.ZINCOVIT ONCE DAILY AT 2PM
5)TAB.PCM 650MG ORALLY/SOS
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