dengue 60,000
A 40 year old male, labourer by occupation came with c/o
1/11/21
1.fever since 5 days
High grade, Associated with chills
2. Cough since 5 days
Productive type, with mucoid expectoration
The patient was apparently assymptomatic 5 days ago and then he developed fever which was high grade , associated with chills and cough which is productive with mucoid expectoration
Loose stools 7 episodes - 3 days ago
Not associated with nausea, vomiting,burning micturition.
Past h/o
K/c/o - HTN since 3 years
Amlodipine 5 mg
Metoder xl 50 mg
Not a k/c/o DM, asthma , epilepsy, TB, CVD
PERSONAL HISTORY
He takes mixed diet
Appetite - normal
Sleep - adequate
Bowel and bladder movements- regular
Addictions - drinks alcohol occasionally and chews betel leaf
On general physical examination
Patient is conscious,coherent, cooperative
Moderately built and nourished
No pallor ,icterus,clubbing,edema of feet,koilonychia, edema of feet
Vitals:-
Temperature- 101.2° F
Pr- 84 BPM
BP- 170/110 mm hg
RR- 18 cpm
Spo2- 99% at RA
Grbs- 154 mg%
Systemic examination
CVS- S1 S2 +
RS- BAE+
P/A - soft,nontender
CNS- NAD
Investigations:-
Hemogram -
Hb- 15.3 gm%
Tlc- 2200
Plt- 24000
Pcv- 42.3
Mcv- 80.7
Mchc- 36.2
Blood group - O negative
Ns1 positive
Provisional diagnosis
DENGUE FEVER ( NS1 POSITIVE) WITH THROMBOCYTOPENIA
Temperature charting
Hemogram
Hb-13.9
Lymphocytes-53
Neutrophils-38
Plt-60,000
Smear - normochromic normocytic with relative lymphocytosis and thrombocytopenia
Soap notes day 1
S- passed black coloured stools twice
O-
Vitals
Temp - afebrile
Pr- 82 BPM
Bp- 120/80 mm hg
Cvs- s1,S2 +
Rs- bae+
P/a- soft, nontender
Cns- nad
A- DENGUE FEVER ( NS1 POSITIVE) WITH THROMBOCYTOPENIA
(Plt count- 60,000)
P
Rx
1. IVF NS,RL,DNS @150 ml/hr
2. Tab.pan 40 mg po OD bbf
3. Syp.ascoryl ls 10 ml po bd
4. Tab dolo 650 mg po sos
5. Tab.amlong 5 mg po od
6. Tab.met xl 50 mg po od
7. W/f bleeding manifestations
SOAP NOTES day 2
40 yr male
S- pt feeling better than yesterday
O-
Temp-afebrile
BP-120/80
PR- 80 BPM
Cvs- S1 ,S2 heard
RS-BAE +,NVBS
P/A soft,non tender
CNS-NAD
A-Dengue fever (Ns1 positive)
K/c/o HTN since 3 yrs
P-
1)IVF - NS ,DNS,RL 150ml/hr
2)Tab.Dolo 650 mg/po /sos
3)TAb.pantop 40 mg po/OD/BBF
4)Tab.Met XL 50 mg po/OD
5)syp.Ascoryl 10 ml po/sos
6)syp.mucaine gel 10 ml po /TID
7)w/f bleeding manifestations
8)monitor BP/PR/RR/SpO 2
SOAP NOTES day 3
40 yr male
S- pt feeling better than yesterday
O-
Temp-afebrile
BP-120/70
PR- 85BPM
Cvs- S1 ,S2 heard
RS-BAE +,NVBS
P/A soft,non tender
CNS-NAD
A-Dengue fever (Ns1 positive)
Plt count- 90,000
K/c/o HTN since 3 yrs
P-
1)IVF - NS ,DNS,RL 150ml/hr
2)Tab.Dolo 650 mg/po /sos
3)TAb.pantop 40 mg po/OD/BBF
4)Tab.Met XL 50 mg po/OD
5)syp.Ascoryl 10 ml po/sos
6)syp.mucaine gel 10 ml po /TID
7)w/f bleeding manifestations
8)monitor BP/PR/RR/SpO 2
SOAP NOTES day 4
Ward case
40 yr male
S-no present complaints
O-
Temp-afebrile
BP-120/80
PR- 85 BPM
Cvs- S1 ,S2 heard
RS-BAE +,NVBS
P/A soft,non tender
CNS-NAD
A-Dengue fever (Ns1 positive)
K/c/o HTN since 3 yrs
P-
1)IVF - NS ,DNS,RL 150ml/hr
2)Tab.Dolo 650 mg/po /sos
3)TAb.pantop 40 mg po/OD/BBF
4)Tab.Met XL 50 mg po/OD
5)syp.Ascoryl 10 ml po/sos
6)syp.mucaine gel 10 ml po /TID
7)w/f bleeding manifestations
8)monitor BP/PR/RR/SpO 2
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