fever projr dengue 202407923 55/f
Diagnosis
DENGUE WITH THROMBOCYTOPENIA (NS1` POSITIVE)
ACUTE KIDNEY INJURY (RESOLVING)
DENOVO HYPERTENSION
K/C/O HYPOTHYROIDISM SINCE 3 YEARS
Case History and Clinical Findings
PATIENT CAME TO CASUALITY WITH C/O FEVER SINCE 5 DAYS
HOPI:PATIENT WAS APPARENTLY ASYMPTOMATIC 5 DAYS AGO , THEN SHE DEVELOPED FEVER SINCE 5 DAYS , LOW GRADE , INSISDIOUS IN ONSET , INTERMITTENT TYPE, NOT ASSOCIATED WITH CHILLS AND RIGORS AGGRAVATED DURING NIGHT AND RELIEVED ON MEDICATION .
H/O NAUSEA SINCE 1 DAY
NO H/O VOMITING , ABDOMINAL PAIN , BURNING MICTURITION , CONSTIPATION
NO H/O CHEST PAIN , SOB , PLAPITATIONS , SWEATING
NO H/O MYALGIA , ARTHRALGIA
PAST HISTORY :
K/C/O HYPOTHYROIDISM (TAB . THYROXINE 100 MG PO/OD)
N/K/C/O DM , HTN , ASTHMA ,TB , EPILEPSY , CVA . CAD
O/E:
PT IS C/C/C
NO SIGNS OF PALLOR , ICTERUS , CYANOSI, CLUBBING , LYMPHADENOPATHY, EDEMA
VITALS - TEMPERATURE : 98.2 DEGREE FARENHEIT
BP:120/90 MMHG
PR : 76 BPM
RR:18 CPM
SPO2 :99%
GRBS : 146 MG%
CVS : S1 S2 HEARD
RS : BAE + , NVBS
P/A: SOFT , NON TENDER , BOWEL SOUNDS HEARD
CNS : NFND
Investigation
HBsAg-RAPID 18-02-2024 03:52:PM Negative
Anti HCV Antibodies - RAPID 18-02-2024 03:52:PM Non ReactiveWIDAL TEST 18-02-2024 03:52:PMS.typhi 'O' Antibodies No Agglutination seenS.typhi 'H' Antibodies No Agglutination seenS.PARATYPHI 'AH' ANTIBODY No Agglutination seenS.PARATYPHI 'BH' ANTIBODY No Agglutination seen
COMPLETE URINE EXAMINATION (CUE) 18-02-2024 03:52:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN ++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilBLOOD UREA 18-02- 2024 03:52:PM 33 mg/dl 42-12 mg/dl
SERUM CREATININE 18-02-2024 03:52:PM 1.9 mg/dl 1.1-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 18-02-2024 03:52:PMSODIUM 138 mEq/L 145-136 mEq/LPOTASSIUM 3.8 mEq/L 5.1-3.5 mEq/LCHLORIDE 104 mEq/L 98-107 mEq/LCALCIUM IONIZED 1.21 mmol/L mmol/L
BLOOD UREA 18-02-2024 10:41:PM 28 mg/dl 42-12 mg/dlSERUM CREATININE 18-02-2024 10:41:PM 1.2 mg/dl 1.1-0.6 mg/dl
SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 18-02-2024 10:41:PMSODIUM 139 mEq/L 145-136 mEq/LPOTASSIUM 3.5 mEq/L 5.1-3.5 mEq/LCHLORIDE 103 mEq/L 98-107 mEq/LCALCIUM IONIZED 1.21 mmol/L mmol/LT3, T4, TSH 19-02-2024 05:46:AMT3 0.64 ng/ml 1.87-0.87 ng/mlT4 19.97 micro g/dl 12.23-6.32 micro g/dlTSH 18.73 micro Iu/ml 5.36-0.34 micro Iu/ml
LIVER FUNCTION TEST (LFT) 19-02-2024 04:06:PMTotal Bilurubin 0.64 mg/dl 1-0 mg/dlDirect Bilurubin 0.20 mg/dl 0.2-0.0 mg/dlSGOT(AST) 84 IU/L 31-0 IU/LSGPT(ALT) 27 IU/L 34-0 IU/LALKALINE PHOSPHATASE 377 IU/L 98-42 IU/LTOTAL PROTEINS 5.4 gm/dl 8.3-6.4 gm/dlALBUMIN 3.0 gm/dl 5.2-3.5 gm/dlA/G RATIO 1.23
USG ABDOMEN AND PELVIS
IMPRESSION - GRADE 1 FATTY LIVER
GALL BLADDER WALL EDEMA
RIGHT RENAL CALCULI
MINIMAL INTERBOWEL FLUID NOTED
2D ECHO :
TRIVIAL MR/TR , NO PAH , NO MS/AS
NO RWMA
GOOD LV SYSTOLIC FUNCTION
GRADE 1 DIASTOLIC DYSFUNCTION
NO PE /CV CLOTS
HEMOGRAM :19/2/24
HB : 10 MG /DL
TLC; 11200
N/LE/M/B:30/60/1/9/00
PCV : 29.2
MCV : 77.9
MCH : 26.7
MCHC : 26.7
RDW CV 15.3
RBC 3.75
PLT : 20000
HEMOGRAM :20/2/24
HB : 12 MG /DL
TLC; 13000
N/L/E/M/B:35/53/2/10/00
PCV : 34.5
MCV : 78.0
MCH : 27.1
MCHC : 34.7
RDW CV 14.6
RBC 4.42
PLT : 75000
HEMOGRAM :21/2/2
HB : 11.3 MG /DL
TLC; 11000
N/L/E/M/B:33/55/1/11/00
PCV : 33.6
MCV : 79.0
MCH : 26.6
MCHC : 33.7
RDW CV 14.5
RBC 4.26
PLT : 74000
HEMOGRAM :22/2/24
HB : 11.6 MG /DL
TLC; 9000
N/L/E/M/B:34/52/2/10/00
PCV : 33.8
MCV : 77.4
MCH : 26.6
MCHC : 34.4
RDW CV 15.4
RBC 4.36
PLT : 80 000
Treatment Given(Enter only Generic Name)
1 SDP TRANSFUSION ON 19/2/24
IVF 2 NS @ 75 ML/HR
INJ NEOMOL IM IV/SOS (IF TEMP> 101 F)
TAB PCM 650 MG PO/SOS
TAB THYRONORM 100MCG PO/OD (8AM -X-X)
TAB MVT PO/OD (X-2PM -X)
TAB AMLONG 5MG PO/OD (8AM -X-X)
WATCH FOR ANY BLEEDING MANIFESTATIONS
MONITOR VITALS 2HRLY
OINT THROMBOPHOBE LA B/D
SYP CREMAFFIN PLUS 15 ML PO/HS (X-X-9PM)
Advice at Discharge
TAB DOLO 650 PO/SOS
TAB THYRONORM 100MCG PO/OD 8 AM FROM MONDAY TO SATURDAY CONTINUE
TAB THYRONORM 125 MCG PO/OD 8 AM EVERY SUNDAY X 45 DAYS(6 TIMES)
NEUROBIONE FORTE PO/OD 2PM X 15 DAYS
TAB AMLONG 5MG PO/OD 8 AM CONTINUE
OIT THROMBOPHOBE L/A FOR 3 DAYS
SYRUP CREMAFFIN PLUS PO/HS 15ML@ 9PM BEFORE SLEEP
PLENTY OF ORAL FLUIDS
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