General medicine Case
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
A 32 old male , mason presented to the opd with chief complaint of fever, cold , cough , headache and giddiness since 1 week
History of present illness :
Patient was diagnosed with dengue fever 1 week back where he had complained of low grade , intermittent fever with no diurnal variation associated with non productive cough and cold also complained of difguse headache with photophobia or phonophobia , giddiness especially on getting up from bed 1 week
Past history:
Not a known case of diabetes , hypertension , epilepsy, Asthma, tuberculosis
No similar histor in the past
He was biten by dog in his childhood of which he got 7 sutures infront of right ear , since then he was not able to hear properly
Personal history :
Diet : mixed
Appetite: decreased
Sleep : adequate
Bowel movements : regular
Bladder movements: burning micturition
Alcohol consumption since 5 years
No history of smoking
General examination:
Patient is conscious, coherent and cooperative
Vitals:
Temp : 98.6F
BP: 110/70
PR: 62 bpm
RR: 20
Spo2: 99% on room air
CVS: S1,S2 heard
RS: BAE +,NVBS
P/A: soft , NonTender
Bowel sounds heard
CNS: NAD
Provisional diagnosis:
Dengue fever with NS1 Antigen positive with thrombocytopenia
Investigations :
On 25 - 10 - 21
USG ABDOMEN :
On 26 -01-21
Blood group : B positive
PLT count: 30,000
On 27 -10 -21
PLT count: 60,000
On 28-10-21
PLT count : 1.30 lakhs
Treatment given :
Treatment given :
-IVF NS , RL @ 125 ml/hr
-INJ PANTOP 40 MG /IV/OD
-INJ ZOFER 4 MG /IV/SOS
-TAB DOLO 650 /PO/ SOS
-INJ NEOMOL 100 ML IV / IF TEMP > 101 F
-SYRUP GRILLINCTUS 10 ML PO/OD /TID WITH 1 GLASS OF WATER
-TEMP CHARTING 4 TH HRLY , TEPID SPONGING
-MONITER VITALS
-POSTURAL BP MONITERING 4 TH HRLY
-PLENTY OF ORAL FLUIDS .
Soap notes:
Day 1
26 -10 -21
Fever chart:
No fever spike, cough , cold subsided
On examination :
PR 84 bpm
BP 110/70 mmHg
RR 18 cpm
Temp 98.2 F
GRBS 105 mg/dl
CVS :
S1 S2 heard , no murmurs
A: Dengue fever with NS1 Antigen positive with thrombocytopenia
Treatment given :
-IVF NS , RL @ 125 ml/hr
-INJ PANTOP 40 MG /IV/OD
-INJ ZOFER 4 MG /IV/SOS
-TAB DOLO 650 /PO/ SOS
-INJ NEOMOL 100 ML IV / IF TEMP > 101 F
-SYRUP GRILLINCTUS 10 ML PO/OD /TID WITH 1 GLASS OF WATER
-TEMP CHARTING 4 TH HRLY , TEPID SPONGING
-MONITER VITALS
-POSTURAL BP MONITERING 4 TH HRLY
-PLENTY OF ORAL FLUIDS .
Soap notes :
Day 3 28 /10 /21
Fever chart:
No fever spike, cough , cold subsided
On examination:
PR 81bpm
BP 110/70 mmHg
RR 18 cpm
Temp 98.6 F
GRBS 93 mg/dl
CVS :
S1 S2 heard , no murmurs
A: Dengue fever with NS1 Antigen positive with thrombocytopenia
Treatment given :
-IVF NS , RL @ 125 ml/hr
-INJ PANTOP 40 MG /IV/OD
-INJ ZOFER 4 MG /IV/SOS
-TAB DOLO 650 /PO/ SOS
-INJ NEOMOL 100 ML IV / IF TEMP > 101 F
-SYRUP GRILLINCTUS 10 ML PO/OD /TID WITH 1 GLASS OF WATER
-TEMP CHARTING 4 TH HRLY , TEPID SPONGING
-MONITER VITALS
-POSTURAL BP MONITERING 4 TH HRLY
-PLENTY OF ORAL FLUIDS .
Comments
Post a Comment