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A 40 yr old male patient wage worker by occupation came to opd with cheif compliant of fever since once week and decreased platelet count .
History of present illness:
Patient was apparently asymptomatic 1 week back then he developed high fever then he visited a nearer medical care centre and diagnosed as typhoid and treatment is given and for 2 days he was alright.
And later after two days again he developed fever and chills during night time and serve weakness that he was not able to take food then he visited nearer hospital and diagnosed as decreased platelet count with hyperpyrexia then referred to our hospital.
Past history:
He is a known case of hypertension since 4 yrs and he is on medication.
And not a known case of diabetes ,epilepsy, TB and asthma.
Personal history:
Diet :mixed
Appetite :Normal
Bowel and bladder movements :regular
Sleep: adequate
Family history:
No history of similar complaints in the family.
Treatment history :
No history of allergy to known drugs.
General examination:
Patient was concious coherent and coperative well oriented to time place and person.
- Pallor absent
-Clubbing absent
-dysnea absent
- pedal edema absent
-No generalized lymphedenopathy.
Vitals:
Temperature : Afebrile
Pulse rate : 81 bpm
Respiratory rate : 17 cycles per min
Bp: 120/70 mm of Hg
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
Inspection :
Chest wall is bilaterally symmetrical
No Precordial bulge
No visible pulsations, engorged veins,scars, sinuses
Palpation :
JVP - normal
Apex beat : felt in the left 5th intercostal space
In midclavicular line
Auscultation :
S1 ,S2 Heard
RESPIRATORY SYSTEM
Bilateral airway +
Position of trachea- central
Normal vesicular breath sounds - heard
No added sounds
PER ABDOMEN
Abdomen is soft and non tender
Bowel sounds heard
CENTRAL NERVOUS SYSTEM
Patient is conscious
Reflexes are normal
Speech is normal.
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
Inspection :
Chest wall is bilaterally symmetrical
No Precordial bulge
No visible pulsations, engorged veins,scars, sinuses
Palpation :
JVP - normal
Apex beat : felt in the left 5th intercostal space
In midclavicular line
Auscultation :
S1 ,S2 Heard
RESPIRATORY SYSTEM
Bilateral airway +
Position of trachea- central
Normal vesicular breath sounds - heard
No added sounds
PER ABDOMEN
Abdomen is soft and non tender
Bowel sounds heard
CENTRAL NERVOUS SYSTEM
Patient is conscious
Reflexes are normal
Speech is normal.
Investigations:
NS1 antigen positive.
Haemogram:
Haemoglobin : 15.3 gm /dl
Wbc : 2,200 cells/cmm
Platelets : 60,000 cells/cmm.
Urine examination:
Blood urea : 44 mg/dl
Creatinine : 0.9 mg/dl.
Electrolytes :
Na+: 132 meq /L.
K+: 41 meq/ L.
Cl- :95 meq/L.
Fever chart :
Treatment :
Tab Dolo 650 mg
Tab pantop 40mg OD.
Tab amlong 5mg PO /OD.
Tab met -XL 50 mg Po/OD
Syrup ascoril 10ml PO/BD .
Diagnosis : dengue
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