Dengue
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A 26 year old male came with chief complaints of fever since 20 days
HOPI : pt was apparently asymptomatic 20 days back then he had low grade fever ,intermittent, not associated with chills and rigors ,relieved by taking medication
From 4 days pt is having continous fever , not relieving on taking medication , not associated with chills and rigors
-no diurnal variation
No vomitings,loose stools,pain abdomen,malena ,bleeding gums
-He went to a local hospital 4 days back where he was tested DENGUE NS1 POSITIVE
And platelet counts :
On 18/08/2021 - 2.60000
On 19/07/2021- 1,32,000
On 21/08/2021 - 23,000
He is referred to our hospital in the view of low platelet counts (23,000)
PAST HISTORY :
N/k/c/o DM,HTN,EPILEPSY ,TB, ASTHMA
PERSONAL HISTORY :
Diet : mixed
Appetite : normal
Bowel and bladder : normal
Sleep :adequate
Addictions:none
FAMILY HISTORY :
not significant
GENERAL EXAMINATION
O/E pt is c,c,c
Moderately built
No pallor ,icterus, cyanosis, clubbing, lymphadenopathy ,edema of feet
Vitals :
Temp : 100.4
Bp :80/40
PR: 78
Rr: 20
Spo2: 96%
Cvs : s1 s2 heard ,no murmurs
CNS: NAD
RS: B/L Air entry present with normal vesicular breath sounds
PA : soft , non tender , no organomegaly
PROVISIONAL DIAGNOSIS :VIRAL PYREXIA WITH THROMBOCYTOPENIA (dengue NS1 positive )
INVESTIGATIONS :
ON 22/08/2021 :
Hemogram :at 6:am
Hb 13.6
TC:# 2400
N:60
L:30
E:04
M:06
B:00
Platelet count : 23,000
At 6 :00pm
Hb:13.3
TLC :2000
Platelets: 26,000
RFT:
Blood urea :12 mg/dl
Sr creatinine:#0.7
Na+ :135
K+. 3.5
Cl- # 92
LFT :
Tb-0.75
Db-0.16
SGOT- #85
SGPT-# 84
ALP- 88
Total protiens-# 4.6
Albumin- #2.97
A/G ratio- 1.82
RBS : #88 mg/dl
Rapid anti HCV antibodies : -ve
HBsAg rapid : -ve
HIV rapid : -ve
ECG :
Ultra sound :
On 23/08/2021 6:00am
8:00pm 1 hr after SDP TRANSFUSION
SOAP NOTES
Day2
Subjective :
Pt complaints of giddiness ,abdominal tightness
Objective :
Temp:98
PR:72
RR: 22
BP: 90/60 mmhg
Grbs :95
Palatal petechia
Assessment-VIRAL PYREXIA WITH THROMBOCYTOPENIA (DENGUE NS1 positive) with platelet count 26,000 today
Plan of treatment :
IVF -NS,RL @100ml/hr
TAB DOLO 650 mg /po/TID
INJ NEOMAL 1gm /iv/sos
Bp /temp/ RR/ spo2 monitoring 6th hrly
Temp monitoring 2nd hrly
Inj.PANTOP 40mg iv /od
Inj ZOFER 4 mg /iv/sos
Plenty of oral fluids
One unit SDP transfused
On24/08/2021
SOAP NOTES
Day 3
Subjective :
Pt complaints of abdominal tightness
Giddiness resolved
Objective :
Temp:98
PR:70
RR: 22
BP: 100/70mmhg. Supine
Standing - 1 min: 100/70
3 min:100/70
5min:100/70
Assessment-
Hb:13.5
Tlc:2500
Platelet count: 55,000 (1 hr after SDP Transfusion)
VIRAL PYREXIA WITH THROMBOCYTOPENIA (DENGUE NS1 positive)
Plan of treatment :
IVF -NS,RL @100ml/hr
TAB DOLO 650 mg /po/TID
INJ NEOMAL 1gm /iv/sos
Inj.PANTOP 40mg iv /od
Inj ZOFER 4 mg /iv/sos
Plenty of oral fluids
Bp /temp/ RR/ spo2 monitoring 6th hrly
Temp monitoring 2nd hrly
On 25/08/2021
SOAP NOTES
Subjective :
abdominal tightness decreased
Objective :
Temp:97
PR:76
RR: 22
BP: 110/70mmhg
Assessment-
Hb:12.1
Tlc:3400
Platelet count: 72000(24 hrs after SDP Transfusion)
VIRAL PYREXIA WITH THROMBOCYTOPENIA (DENGUE NS1 positive)
Plan of treatment :
IVF -NS,RL @100ml/hr
TAB DOLO 650 mg /po/TID
INJ NEOMAL 1gm /iv/sos
Inj.PANTOP 40mg iv /od
Inj ZOFER 4 mg /iv/sos
Plenty of oral fluids
Bp /temp/ RR/ spo2 monitoring 6th hrly
Temp monitoring 2nd hrly
On 26/08/2021
SOAP NOTES
Subjective :
Itching over hands
abdominal tightness resolved
No fever spikes
Objective :
Temp:97
PR:76
RR: 22
BP: 110/70mmhg
Assessment-
Hb:12.1
Tlc:4200
Platelet count: 1.13
VIRAL PYREXIA WITH THROMBOCYTOPENIA (DENGUE NS1 positive)
Plan of treatment :
IVF -NS,RL @100ml/hr
TAB DOLO 650 mg /po/TID
INJ NEOMAL 1gm /iv/sos
Inj.PANTOP 40mg iv /od
Inj ZOFER 4 mg /iv/sos
Plenty of oral fluids
Bp /temp/ RR/ spo2 monitoring 6th hrly
Temp monitoring 2nd hrly
Planned for discharge
