55yr old male with dengue

 55yr/M with dengue

CBBLE UDHC SIMILAR CASES

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.


A 55 yr old male patient came to opd with chief complaints of fever and headache since 5days.


History of present illness:— patient was apparently asymptomatic  8 days back,then he developed low grade fever which is intermittent and is not associated with chills and rigors. Fever relieves on medication.

Headache is in frontal region and is not associated with vomitings ,giddiness and blurring of vision.


No history of malena or hematuria.


Past history:— No H/O dm,htn,thyroid,asthma,epilepsy.


Family history:— not significant

Treatment history:— none


Personal history:— 

Married

Diet-mixed

Appetite:- decreased 

Sleep:- not adequate

Bowel and bladder movements- normal

Addictions:— alcohol consumption everyday.


General examination:— patient is concious, coherent and cooperative.

                Vitals:— Temp:- 98 F

                Rr:- 20/min

                Pr:-64/min

                Bp:—supine - 100/70mmhg

                          Stand after 3min - 90/70 mmhg

                 Grbs:—


No c/k/o pallor,icterus,cyanosis,clubbing,lymphadenopathy and edema.



Systemic examination:— 

CVS:— S1 and S2 heard no murmers

Rs:- BAE- normal

CNS:— NAD

PA :— soft and nontender.


INVESTIGATIONS:—




ECG:—





Hemogram—
Platelet count :— 11000 (reduced) of increased to 12000 on the next day.





Serology:— NS-1 positive 

Usg:—




CUE :-
Colour pale yellow
Albumin +++
Pus cells 4 - 5
Epithelial cells 2- 4

RBS : 114

MP - ve

Mp strip -be

RFT: -
Urea : 35 mg/DL
Creatinine : 1.2
Uric acid : 6.1
Ca+2 : 9.9
Phosphorus : 3.5
Na+ : 138
K+ : 3.7
Cl- : 98

LFT
TB : 0.73
DB : #0.26
SGOT :#102
SGPT:#50
ALP:#234
TP:6.4
ALB : 3.7
A/G ratio : 1.35

Provisional diagnosis 
Viral pyrexia with thrombocytopenia
With NS1 +

Treatment 
1) IVF ns , RL at 125ml/min
2) INI ZOFER 4mg IV sos
3) temp monitoring every hourly
4) Bp monitoring every 4th hourly
5) w/f bleeding manifestation
6) strict i/o charting
7) GRBS monitoring 6th hrly


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