Fever projr dengue

 Diagnosis

date of admission 27/1/2024 

date of discharge 29/1/2024



DENGUE FEVER, WITH THROMBOCYTOPENIA, NS1 POSITIVE

DENOVO TYPE 2 DM

Case History and Clinical Findings

PATIENT CAME WITH C/O FEVER SINCE 10 DAYS, COUGH, COLD WITH 10 DAYS, LOOSE WATERY STOOLS 10 DAYS BACK

PATIETN WAS APPARENTLY ASYMPTOMATIC 10 DAYS AGO , THEN DEVELOPED FEVER LOW GRADE, ASSOCIATED WITH CHILLS AND RIGORS, PERIODIC, ASSOCIATED WITH COUGH, COLD 10 DAYS BACK, DRY COUGH AND RESOLVED 5 DAYS BACK.

LOOSE STOOLS , NON BLOOD STAINED, 3-4 EPISODES 10 DAYS BACK, RESOLVED 5 DAYS BACK

NO H/O VOMITING, BURNING MICTURITION

PAST HISTORY

NO H/O HTN, DM, TB, ASTHMA, EPILEPSY

NO ADDICTIONS

PERSONAL HISTORY:

DIET:MIXED

SLEEP:ADEQUATE

BOWEL AND BLADDER:REGULAR

ADDICTIONS:NO

APPETITE:NORMAL

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON.

NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA.

VITALS:

TEMPERATURE:98.6

BP:120/80 MM HG

PR:84 BPM

RR:18 CPM

SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD NO MURMURS.

RS:BAE +,NO MURMURS

PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY

CNS:NO FOCAL NEUROLOGICAL DEFICITS.

Investigation

HBsAg-RAPID 27-01-2024 08:26:PM Negative

BLOOD UREA 27-01-2024 08:26:PM 29 mg/dl 42-12 mg/dl

SERUM CREATININE 27-01-2024 08:26:PM 1.6 mg/dl 1.1-0.6 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 27-01-2024 08:26:PM

SODIUM 142 mEq/L 145-136 mEq/L

POTASSIUM 3.4 mEq/L 5.1-3.5 mEQ/L

CHLORIDE 104 mEq/L 98-107 mEq/L

CALCIUM IONIZED 1.21 mmol/L mmol/L

LIVER FUNCTION TEST (LFT) 27-01-2024 08:26:PM

Total Bilurubin 0.74 mg/dl 1-0 mg/dl

Direct Bilurubin 0.16 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 152 IU/L 31-0 IU/L

SGPT(ALT) 104 IU/L 34-0 IU/L

ALKALINE PHOSPHATE 140 IU/L 141-53 IU/L

TOTAL PROTEINS 6.3 gm/dl 8.3-6.4 gm/dl

ALBUMIN 3.7 gm/dl 4.6-3.2 gm/dl

A/G RATIO 1.43

COMPLETE URINE EXAMINATION (CUE) 27-01-2024 08:26:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN Nil

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 2-3

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

POST LUNCH BLOOD SUGAR 28-01-2024 07:52:AM 221 mg/dl 140-0 mg/dl

RFT 28-01-2024 10:54:PM

UREA 47 mg/dl 42-12 mg/dl

CREATININE 1.5 mg/dl 1.1-0.6 mg/dl

URIC ACID 4.9 mg/dl 6-2.6 mg/dl

CALCIUM 9.1 mg/dl 10.2-8.6 mg/dl

PHOSPHOROUS 2.4 mg/dl 4.5-2.5 mg/dl

SODIUM 143 mEq/L 145-136 mEq/L

POTASSIUM 3.6 mEq/L 5.1-3.5 mEq/L

CHLORIDE 106 mEq/L 98-107 mEq/L

HB- 10.1

TLC- 7400

PLATELETS- 1.2 LAKHS

RBC-3.47 MILLION

Treatment Given(Enter only Generic Name)

IVF 1 NS AT 75 ML/HR

CAPSULE DOXYCYCLINE 100 MG BD X 2 DAYS

TAB. PARACETAMOL 650 SOS

TAB. MVT OD

TAB PAN 40 OD


TAB GLIPIZIDE 2.5 MG PO OD

Advice at Discharge

CAPSULE DOXYCYCLINE 100 MG BD X 1 DAY 1-0-1

TAB. PARACETAMOL 650 SOS X 5 DAYS 1-0-1

TAB. MVT OD X 5 DAYS 0-1-0

TAB PAN 40 OD X 5 DAYS

TAB GLIPIZIDE 2.5 MG PO OD

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