03 Sai Tarun

Diagnosis- viral pyrexia (dengue NS1 positive)

UNIT 5ADMISSION:

Chief complaints
A 14year old male resident of chanduru came in to casualty with chief complaints of 
fever since 4 days. C/o cough since 4days

Presenting illness
Patient was apparently asymptomatic 4 days back then he developed fever which is of incidious in onset, intermittent and is of high  grade fever,a/w chills and body pains.
C/O cough since 4 days which is associated with sputum . 
Patient has  h/o  1episode of vomiting 2days back which is non bilious,non projectile.
No h/o pedal oedema,decreased urine output,sob,palpitations.
No h/o chest pain,abdominal pain

PAST HISTORY:
Not a k/c/o HTN,DM, CAD, asthma, TB, epilepsy.


PERSONAL HISTORY:
Patient has mixed diet with normal appetite and adequate sleep. 
he has normal bowel movements and bladder filling. 
No addictions. 
FAMILY HISTORY
No significant family history or allergic history. 

GENERAL EXAMNATION:
Patient is c/c/c with moderate built and moderate nourishment. 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema. 
VITALS:
BP: 100/80 MMHG, 
PR: 90bpm 
Temp: 98.2°F, 
RR: 22 CPM, 
SPO2: 98% 

RS: BAE+,NVBS

9: S1 ans S2 heard. No murmurs. 
P/A: soft and non-tender. 
CNS: No focal deformities. 

INVESTIGATIONS:
1) HEMOGRAM : 
Hb: 12.6
TLC: 4,200
PCV: 37.6

2) LFT:
TB: 0.76
DB: 0.25
SGOT: 51
SGPT: 21
AP: 519
TP: 6.3
A: 2.2
A/G: 0.55


3)CUE
Alb:trace
Sug:nill
Ec:2-3
Pc:2-3
RBC:bill



4)BLOOD UREA:34

 5)SERUM ELECTROLYTES:
Na+:136
K+:4.1
Cl-:102

Absolute neutrophil count"-

Peripheral smear:-

Rapid dengue test:-




Fever chart








PLT: 3.41
SOAP NOTES DAY 1:-

AMC case
S- complains of fever,cold,cough 
O-bp-130/100
Pr-89
Rr-17
Cvs-s1,s2 heard
Resp- bae +
Per abdomen-soft,non tender,bowel sounds present.
A- viral pyrexia (Dengue NS1 positive)
P-
IV FLUIDS-NS,RL @ 75 ml/hr
Tab.augmentin 625 mg po/bd
Tab.dolo 650 mg po/tid
Inj.pan 40 mg/po/od
Inj.optineuron 1 amp in 100 ml NS IV od
Syr.grillinctus bm 100 ml/po/tid
Plenty of oral fluids
Inj.neomol 1 g/IV/sos only if temperature greater than 101°F
Watch for bleeding manifestations and postural drop.

Soap notes day 2:-

AMC case
14/M
S- no fresh complaints
O-bp-90/60
Pr-88
Rr-17
Cvs-s1,s2 heard
Resp- bae +
Per abdomen-soft,non tender,bowel sounds present.
A- viral pyrexia (Dengue NS1 positive)
P-
IV FLUIDS-NS,RL @ 25 ml/hr
Inj.augmentin 1.2g iv/OD
Tab.dolo 650 mg po/tid
Inj.pan 40 mg/po/od
Inj.optineuron 1 amp in 100 ml NS IV od
Syr.grillinctus bm 100 ml/po/tid
Plenty of oral fluids
Inj.neomol 1 g/IV/sos only if temperature greater than 101°F
Watch for bleeding manifestations and postural drop.

Soap notes day 3:-
AMC case
14/M
S- 1fever spike ,no fresh complaints
O-bp-100/70mmhg
Pr-80
Rr-20
Cvs-s1,s2 heard
Resp- bae +
Per abdomen-soft,non tender,bowel sounds present.
A- viral pyrexia (Dengue NS1 positive)
P-
IV FLUIDS-NS,RL @ 100ml/hr
Inj.augmentin 1.2g iv/BD
Inj PCM 1gm IV/sos
Inj.Zofer 4 mg/IV/sos
Tab. Doxycycline 100mg/po/bd
Syr.grillinctus bm 100 ml/po/tid
Plenty of oral fluids
Watch for bleeding manifestations and postural drop.
Strict temp monitoring 4th hrly

PROVISIONAL DIAGNOSIS:DENGUE FEVER NS1positive

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