25 yrs old female with dengue fever
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25 yr old female housewife by occupation resident of nalgonda came to general medicine OPD with
Chief complaints:-
Body pains since 6 days
Fever since 3 days
History of presenting illness:-
Patient was apparently asymptomatic 6 days back then she started developing body pains insidious in onset ,gradually progressive, dragging type symmetrica in nature small joints are involved more not associated with swelling local rise of temperature and redness,aggravated during fever no relieving factors
Fever since 3 days sudden in onset continues in nature high grade associated with chills and rigors relieving on medication no aggravating factors
Headache since 3 days during fever dragging type relived on medication and rest
History of Vomitings 4 days back projectile type non bilious 3-4 episodes
History of watery loose stools 4 days back 3-4 episodes
History of petechial rash on left fore arm one day of admission after applying Bp cuff
No history of cough,night sweats, abdominal pain,pedal oedema,retro orbital pain.
Past history:-
She is not a known case of diabetes, hypertension,asthma,CAD,epilepsy,TB,and thyroid disorders.
Family history:-
Not significant
Personal history:-
Diet-mixed, loss of Appetite ,Sleep-adequate Bowel and bladder movements -normal Addictions-no,no allergies.
DAILY ROUTINE:
*Before illness
Patient wakes up at 8:00 Am
Do breakfast at 9:00 Am
Does daily household work
Then have lunch at 1:00 Pm
Snacks with milk at 5:00 Pm
Have dinner at 9:00 Pm
And then sleep before 11:00 Pm.
*After illness
Now she is waking up at 9:00 Am
Not doing daily work
she is unable to eat because of loss of appetite and her mother is feeding her.
Lunch- 1/4 cup rice with dal
Sleeps till 6:00 Pm evening
Wakes up at 6:00 Pm
No snacks
Eats dinner at 9:00 Pm
Sleeps at 11:00 pm
Menstrual history:-
Age of menarche -13 years Cycles- regular 3/28,Pads 3 pads/day,Clots and pain abdomen absent
GENERAL EXAMINATION
The patient is conscious coherent cooperative well oriented to time place and person
She is moderately built and nourished
Pallor - absent ,Icterus -absent ,Cyanosis-absent ,Clubbing -absent ,Edema -absent,Lymphadenopathy -absent
Vitals:-
Temp 99F
BP-100/80 mm of Hg
RR 21 Cpm
PR - 82 bpm
Spo2 -98%
GRBS -203
SYSTEMIC EXAMINATION
CVS: S1, S2 heard,No thrills and cardiac murmurs
Respiratory:- No dyspnoea, wheezing, trachea - central, Breath sounds - Vesicular
Per Abdomen Examination:
INSPECTION:
Shape of abdomen- scaphoid
Umbilicus-central and inverted
Transverse scar is present
No sinuses and engorged veins
Hernial orifices are free
All Quadrants are moving equally with respiration.
PALPATION:
All inspectory findings were confirmed by palpation
No local rise of temperature and tenderness
Liver-
Spleen- not palpable
Kidney- on Bimanual examination not palpable
PERCUSSION:
Shifting dullness:Absent
Fluid thrill: Absent
Liver span:
Percussion of Traube's space: resonant note heard.
AUSCULTATION:
Normal bowel sounds heard
No Bruits were heard.
CNS:
higher mental functions intact,Speech - normal ,No signs of meningeal irritation
Provisional diagnosis:
DENGUE HEMORRHAGIC FEVER with NS1 positive
Investigations
Treatment:-
28/11/23
IV fluids NS @75 ml/hr
Tab. Doxycycline 100mg PO/BD
Inj. Optineuron 1 amp in 100 ml NS IV OD
Temperature 4th hourly
BP monitoring 2nd hourly
Inj. Zofer 4mg IV BD
Inj. Pan 40 mg OD
1 ORS sachet in 1 l water
200 ml ORS after each episode of loose stools
29/11/23
IV fluids NS @200 ml/hr
Tab. Doxycycline 100mg PO/BD
Inj. Optineuron 1 amp in 100 ml NS IV OD
Temperature 4th hourly
BP monitoring 2nd hourly
Inj. Zofer 4mg IV BD
Inj. Pan 40 mg OD
1 ORS sachet in 1 l water
Inj. PCM 1 gm IV if temp > 101F
30/11/23
IV fluids NS @200 ml/hr
Tab. Doxycycline 100mg PO/BD
Inj. Optineuron 1 amp in 100 ml NS IV OD
Temperature 4th hourly
Inj. PCM 1 gm IV if temp > 101F
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