DENGUE FEVER WITH THROMBOCYTOPENIA

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This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

CASE PRESENTATION 

CHIEF COMPLAINTS: 

 COMPLAINTS OF FEVER SINCE 3 DAYS 

 VOMITING SINCE 3 DAYS 

HISTORY OF PRESENT ILLNESS :

PATIENT WAS  APPARENTLY ASYMPTOMATIC 3 DAYS AGO THEN HE DEVELOPED FEVER WHICH IS HIGH GRADE CONTINUOUS TYPE, RELIEVED WITH MEDICATION. IT IS ALSO ASSOCIATED WITH EXCESSIVE SWEATING ,

 2 EPISODES OF VOMITING WHICH IS NON PROJECTILE NONBILIOUS FOOD AS CONTENT.

NO HISTORY OF COUGH OR COLD 

 NO HISTORY OF BURNING MICTURITION 

PAST HISTORY:

NOT A KNOWN CASE OF HYPERTENSION, DIABETES MELLITUS, ASTHMA ,CAD,TUBERCULOSIS AND EPILEPSY.

TREATMENT HISTORY:

NO HISTORY OF TREATMENT IN THE PAST 

PERSONAL HISTORY :

APPETITE is normal

 DIET is mixed

 BOWEL AND BLADDER  is regular

 MATURATION is normal

  ALLERGIS  - NO ALL

HABITS:NOT ALCOHOLIC

 

FAMILY HISTORY:

  NOT SIGNIFICANT 

GENERAL EXAMINATION:

  

 PALLOR ABSENT

 CYANOSIS-ABSENT

 CLUBBING-ABSENT

 LYMPHADENOPATHY-ABSENT

 PEDAL EDEMA ABSENT 

 VITALS 

 BP: 100 / 60 MMHG 

PULSE RATE:  78 BPM

 RESPIRATORY: 16 CPM

 TEMPERATURE: AFEBRILE 

SPO2:  98%

SYSTEMIC EXAMINATION :

 CARDIOVASCULARSYSTEM :

 S1S2 +

 NO THRILLS 

NO MURMURS 

 RESPIRATORY SYSTEM :

 NO WHEEZE 

 NO DYSOPNEA 

VESICULAR BREATHE SOUNDS HEARD 

 PER ABDOMINAL EXAMINATION :

  NO ABNORMALITIES DETECTED 

DIAGNOSIS :

DENGUE FEVER WITH THROMBOCYTOPENIA  NS1 ANTIGEN +

INVESTIGATION :

ECG

HEMOGRAM 

TREATMENT :

15/12/22

1) IV FLUIDS 1 PINT NS AND 1 PINT RL @ 75 ML/ HR 

2)INJ.NEOMOL 1 GM IV/ SOS IF TEMP >101 F

3)TAB. PAN 40 PO/OD

4) INJ.ZOFER 4 MG IV/ SOS 

5)TAB.PCM 650 MG PO/SOS

6)TEMP MONITORING 4 TH HOURLY 

7)VITAL MONITORING 6 TH HOURLY

16/12/22

1) IV FLUIDS 1 PINT NS AND 1 PINT RL @ 75 ML/ HR 

2)INJ.NEOMOL 1 GM IV/ SOS IF TEMP >101 F

3)TAB. PAN 40 PO/OD

4) INJ.ZOFER 4 MG IV/ SOS 

5)TAB.PCM 650 MG PO/SOS

6)TEMP MONITORING 4 TH HOURLY 

7)VITALS MONITORING 6TH HOURLY 

17/12/22

1) IV FLUIDS 1 PINT NS AND 1 PINT RL @ 75 ML/ HR 

2)INJ.NEOMOL 1 GM IV/ SOS IF TEMP >101 F

3)TAB.PCM 650 MG PO/SOS

4)TEMP MONITORING 4 TH HOURLY 

5)VITAL MONITORING 6 TH HOURLY

18/12/22

1) IV FLUIDS 1 PINT NS AND 1 PINT RL @ 75 ML/ HR 

2)INJ.NEOMOL 1 GM IV/ SOS IF TEMP >101 F

3)TAB.PCM 650 MG PO/SOS

4)TEMP MONITORING 4 TH HOURLY 

5) VITALS MONITORING 6TH HOURLY