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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