DENGUE FEVER


20 September 2021


"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome."


A 30yrs male patient presented to the OPD with chief complaint of fever ,generalised  weakness since 3days.


HISTORY OF PRESENT ILLNESS

The patient was apparently asymptomatic 3days back  then presented with fever,chills,cough,headache.

Associated with generalised weaknesss and giddiness.


PAST  HISTORY

History of jaundice 2months back.

No history of diabetes,hypertension,thyroid disorders,asthama.


PERSONAL HISTORY

Diet:mixed

Appetite:decreased

Bowel and bladder:normal

Addictions:alcohol-regular


FAMILY HISTORY

No history of similar complaints in family


TREMENT HISTORY 

No history of durg allergy


GENERAL EXAMINATION

Patient is coherent,conscience and cooperative

No icterus

No pallor

No cyanosis 

No lymphadenopathy

presents of malnutrition and dehydration

Temp-99.7 F

PR-87 bpm

RR-16 cpm

BB-100/60 mm of Hg

GRBS-110 mg/dl


SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM:

Inspection:
S1,S2  heard

Auscultation:
Normal with regular heartbeat

S1, S2 heard

No murmurs 

RESPIRATORY SYSTEM-
Lungs: reduced breath sounds bilaterally.

PER ABDOMEN:
Negative

CENTRAL NERVOUS SYSTEM
Lower limb reflexes absent.

Abdominal reflexes absent.

INVESTIGATION

0N 21/08/2021

HEMOGRAM

  HB:15.7gm/dl
  RBC:4.35mil/cumm
  PLATELETS:35,000l/cumm
 
BLOOD UREA:34mg/dl

SERUM CREATININE:1.0mg/dl

LIVER FUNCTION TEST

   total bilurubin1.31mg/dl
   SGOT:335IU/L
   SGPT:185IU/L
   ALKALINE PHOSPHATE:124IU/L
   ALBUMIN:3.1gm/dl
   TOTAL PROTIENS:5.0gm/dl

ULTRA SOUND SCAN OF ABDOMEN

LIVER: mild hepatomegaly
GB:well edema
minimal free fluid in the abdomen






TREATMENT

ON 21/8/21
 INJ.PAN 40mg IV/OD
 INJ.ONDOSETRON 4mg IV/SOS
 INJ.THIAMINE 14MP IV/TID

ON 22/8/21
 INJ.PAN 4mg IV/OD
 INJ.OPTINEURON 40mg IV/OD
 Tab .THIAMINE IV /TID
 TAB SPOROLAC-ds po/TID

0N 23/8/21 
 INJ.PAN 40mg/OD
 INJ.OPTINEURON 40mgIV/OD
 INJ.THIAMINE 40mg IV/OD








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