dengue case
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A 55 year old male patient daily labourer by occupation ( visited a nearby clinic in narketpally and underwent blood tests) has come to the OPD with the chief complaint of fever since 4 days. associated with chills and rigors.
Not associated with
- body pain
- abdominal pain
-cough
- chills
-head ache
History of present illness:
Patient was apparently asymptomatic 4 days back and then had fever ( low grade) associated with chills and rigors.
Not associated with body pains.
No history of cold and cough.
No history of rashes.
No history of bleeding from gums
No history of hematuria
No history of Malena
No history of medications used
History of past illness:
K/c/o of hypertension since 2 yrs
Has been taken tablets since then
Personal history:
No abnormalities detected
General examination:
No pallor,icterus,cyanosis,clubbing,edema,
lymphadenopathy
Temperature: 98 C
PR : 82 bpm
RR : 18 bpm
Grbs : 161 mg%
SpO2 : 90 %
BP : 160/100 mmhg
CVS- S1S2 +
RS-BAE +
PA-Soft,non tender
CNS-NAD
Investigations:
Diagnosis:
Viral pyremia with thrombocytopenia
NS1 POSITIVE
No bleeding manifestations
Treatment:
IV Fluids NS ,RL@ 200 ml/hr
T.dolo 650 mg po tid
Inj neomol 1gm iv sos
Inj optineuron 10 in 100 ml NS iv /od
Temperature monitoring 4th hrly
Vitals monitoring 6th hrly
Check for any bleeding abnormalities and postural drop
