28 yr old male
Unit 6 admission
ECG-
CHEST X RAY
Temperature charting
soap notes day-1
Soap notes day 4
A 28 year old male came to casualty with
C/o fever since 5 days
Pain abdomen since 5 days
H/o vomitings 5 days back
Fever- high grade, intermittent not associated with chills and rigor, relieved on medications
Diffuse type of pain abdomen
Vomitings 5 days back- non projectile,non bilious, food as content
No h/o vomitings and loose stools at present
No h/o Malena/rash/bleeding gums
No h/o cold, cough,sob
Went to local hospital -tested dengue NS1 positive brought to our hsptl I/v/o low platelet count (23,000 on 9/10/21)
PAST HISTORY
No h/o DM, HTN, asthma, TB epilepsy
PERSONAL HISTORY
Farmer by occupation
Appetite-decreased
Regular bowel and bladder movements
No addictions
GENERAL EXAMINATION :
Patient is conscious, coherent and cooperative
No pallor, Icterus, cyanosis, clubbing, lymphadenopathy
VITALS :
Temp: 101F
PR: 88bpm
BP: 110/70 mm hg
RR: 20 cpm
Spo2 - 95%
CVS :
S1, S2 heard , No murmurs
RS :
Position of trachea: central
BAE present
PER ABDOMEN: Soft,non tender
Bowel sounds +
CNS:
Patient is Conscious ,oriented to time,place and person
HMF -intact
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
No meningeal signs
PROVISIONAL DIAGNOSIS-
Dengue NS1 positive with thrombocytopenia
Investigations:-
Sujectively :- Patient is complaining of pain abdmonen and abdominal distension
Cough with blood tinged sputum 3 episodes since yesterday night
Objectively : Temp 102 F
Bp -110/80 mm hg
Pr -79 bpm (fever with bradycardia)
Cvs s1s2 heard no murmurs
P/a soft NT
Assesment : Dengue fever
Platelets : 30000 to 23000(yesterday count) pcv 39.6
Plan: IVF continuous infusion
Soap notes day 2
Sujectively : Patient is complaining of pain abdmonen and abdominal distension
Mild headache ,pain in inspiration,
Cough decreased
Objectively : inspiratory crepts +
Temp 101 F
Bp 120/80 mm hg
Pr- 79bpm
Cvs -s1s2 heard no murmurs
P/a -soft, tender
Assesment : Dengue fever
Platelets : 33000
Plan: IVF continuous infusion
Temperature charting day 2
Icu bed 3
Subjective:-pt feeling better than yesterday,abdominal tenderness decreased, loose stools 5-6 episodes
Objectively :
Bp 130/80 mm hg
Pr 73 bpm
Rr 18 cpm
Grbs 88mg/dl
Spo2 96%
Cvs s1 s2 heard, no murmrs
Rs: decreased air entry on right side with fine crepitations
P/a : soft
Assesment : Dengue fever
Plan : IVF NS continuous infusion
Subjective:-pt feeling better than yesterday,abdominal tenderness decreased
Objectively :
Bp 150/90 mm hg
Pr 71 bpm
Rr 18 cpm
Grbs 88mg/dl
Spo2 96%
Cvs s1 s2 heard, no murmrs
Rs: decreased air entry on right side with fine crepitations
P/a : soft
Assesment : Dengue fever
Plan : IVF NS continuous infusion
Soap notes day 6
Subjective:-pt feeling better than yesterday,abdominal tenderness decreased
Objectively :
Bp 160/100 mm hg
Pr 79bpm
Rr 18 cpm
Grbs mg/dl
Spo2 97%
Cvs s1 s2 heard, no murmrs
Rs: decreased air entry on right side with fine crepitations
P/a : soft
Assesment : Dengue fever
Plan : IVF NS continuous infusion
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