18 years old male with fever since 2 days

18 years old male came with complaints of fever since 2 days.

History of present illness- 

The patient was apparently asymptomatic 2 days back. Then he developed: 

1) Fever which was-

• High grade
• Insidious in onset
• Progressive
• Associated with diurnal variation (more in nights)
• Associated with chills and rigors.

2) C/O generalised body pains.

No h/o vomitings, loose stools.
No h/o pain abdomen, rashes over the body.
No h/o headache, neck rigidity, retro-orbital pain, melena, increased bleeding tendencies.
No h/o burning micturition.
No h/o pedal edema, decreased urine output.

Past History: Not a K/C/O DM, HTN, TB, BA, Epilepsy, CVA, CAD.

Personal History: 

• Unmarried
• Occupation- student
• Diet- mixed
• Appetite- Reduced since 2 years
• Sleep- Adequate
• Bowel and bladder habits- Regular
• No addictions

GENERAL EXAMINATION: He is conscious, coherent, cooperative, well oriented to time, place and person. He is moderately built and moderately nourished.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.

VITALS ON ADMISSION:

Temperature- 103 F

PR- 126 bpm

BP- 110/80 mm Hg

RR- 26 cpm

SpO2- 98% @ RA

GRBS- 128 mg/dl

SYSTEMIC EXAMINATION:

CVS- S1, S2 sounds heard.

RS- BAE+, NVBS heard

P/A- Soft, non tender, no organomegaly, Bowel sounds heard

CNS- No FND

INVESTIGATIONS:

11/12/21

Serology- Negative for HIV, HBsAg, RPR

CBP:

Hb- 15 gm/dl

TLC- 9600

Plt- 1.6 lakhs/cu. mm

LFT:

TB- 0.88

DB- 0.19

AST- 34

ALT- 33

ALP- 162

TP- 6.6

ALBUMIN- 3.0

A/G RATIO- 0.86

RFT:

UREA- 14 mg/dl

CREATININE- 1 mg/dl

SODIUM- 143 mEq/L

POTASSIUM- 4 mEq/L

CHLORIDE- 98 mEq/L

CUE:

Colour- pale yellow 

Appearance- clear

Reaction- acidic

Specific gravity- 1.010

Albumin- nil

Sugar- nil

Bile salts-nil

Bile pigments-nil

Pus cells- 2-3

Epithelial cells- 2-3

RBCs- nil

Crystals-nil

Casts-nil

CXR- PA VIEW:

USG ABDOMEN:

Treatment-

1. IV Fluids- RL, NS @100 ml/hour

2. INJ. NEOMOL 1 gm I.V./SOS

3. Tab. PCM 650 mg PO/QID

4. INJ. PAN 40 mg I.V./OD

5. INJ. OPTINEURON 1 amp in 100 ml NS I.V./OD

6. Plenty of oral fluids.

7. BP/PR Monitoring 4th hourly

8. Watch for bleeding manifestations 

SOAP Notes

13/12/21

S:

No fever spikes.

O: Patient consious, coherent, cooperative 

Bp:130/90mhg

Pr:  80 bpm

Cvs: s1 s2+

Rs: BAE+ 

A: Dengue fever with thrombocytopenia. 

P: 

1. IVF NS,RL,DNS@100 ml/hr.

2.Plenty of oral fluids

3. Tab .DOLO 650 MG PO SOS.

4.Tab.pan 40 mg po od.

5.Inj.Neomol 1g IV sos.

6.W/F bleeding manifestations. 

14/12/21

S- 

No C/o malena, bleeding manifestations 

No fever spikes

O-

Pt isC/C/C

Temp- 97.8°F

BP- 110/80 mmHg in supine and standing

PR- 80bpm

CVS- S1S2 +

RS- BAE+

P/A- soft, non tender

A-

DENGUE FEVER WITH THROMBOCYTOPENIA 

P- 

IVF NS,RL,DNS @100ml/hr

Inj.PAN 40mg IV OD

Inj.ZOFER 4mg IV BD 

T.DOLO 650mg PO QID

Inj.OPTINEURIN 1amp in 100ml NS IV OD

Plenty of oral fluids 

W/f bleeding manifestations