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HISTORY :
A 21 yr old female who is a housewife by occupation came with
Chief complaints :
1. Fever since 4 days
2. Vomiting 2- 3 episodes/day since 3 days
3. Body pains since 3 days
HOPI :
Patient was apparently asymptomatic 4 days back then she developed fever, more in the evening associated with chills relieved with medication. Then patient started having vomiting since 3 days 2-3 episodes per day with food as contents, non-projectile, non-bilious and not stained with blood. Patient had body pains since 3 days which was more in lower back, hands and legs which was not relieved with medication.
No h/o headache
No h/o diarrhea, vomiting.
Past History :
No history of similar complaints in the past.
Patient is not a known case of Diabetes mellitus, Hypertension, Tuberculosis, Asthma, Epilepsy, Thyroid disease.
There is no history of blood transfusion or hospital admission.
Personal History :
Diet : Mixed
Appetite: Normal
Sleep : Adequate
Bowel and bladder movements : Regular
Addictions : None
Family History :
No significant family history.
On examination:
Pt conscious, coherent, cooperative, well oriented to time place and person.
Moderately built and moderately nourished.
General Examination : No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema
Vitals:
BP- 110/70mm Hg
PR- 94bpm
RR- 20 cpm
Temp - 98.6
SpO2 - 98%
GRBS- 71 mg/dl
Systemic Examination :
CVS- S1 S2 heard
RS- BAE present
PA - Soft, non-tender
CNS- NAD
Reflexes -
Right side Left side
Biceps - ++ ++
Triceps- ++ ++
Supinator- ++ ++
Ankle - ++ ++
KNEE- ++ ++
INVESTIGATIONS :
1. Hemogram (11-09-22)
2. RBS
3. Serum Creatinine
5. Serum electrolytes
6. Ultrasound
7. Chest X ray
8. Hemogram (12-09-22)
9. Dengue (NS1) - POSITIVE
10. M. P. Strip test
11. Blood grouping and Rh type :
12. Hemogram (13-09-22)
PROVISIONAL DIAGNOSIS :
DENGUE (NS1 POSITIVE WITH THROMBOCYTOPENIA)
TREATMENT :
1)INJ. NEOMAL 1gm IV if temp > 102°F
2) TAB DOLO 650mg PO/ TID
3) INJ PAN 40mg IV / OD
4) INJ ZOFER 4 mg TID/ SOS
5) IVF 10 RL @ 100 ml/ hr
6) TEMP AND VITALS MONITORING 4th hrly
SOAP NOTES :
AMC BED NO.02
admitted on 11/09/2022
DAY- 02
S -
Fever spike not seen
Vomiting - 1 episode
Nausea is present
O-
Patient is conscious, coherent, cooperative and well oriented to time, place and person
VITALS
BP- 110/70mm Hg
PR- 94bpm
RR- 20 cpm
Temp - 98.6
GRBS- 71 mg/dl
SYSTEMIC EXAMINATION
CVS- S1 S2 heard
RS- BAE present
PA - SOFT NON TENDER
CNS- NAD
A -
Dengue fever NS1 positive with thrombocytopenia (platelets - 65000)
P-
1)INJ. NEOMAL 1gm IV if temp > 102°F
2) TAB DOLO 650mg PO/ TID
3) INJ PAN 40mg IV / OD
4) INJ ZOFER 4 mg TID/ SOS
5) IVF 10 RL @ 100 ml/ hr
6) TEMP AND VITALS MONITORING 4th hrly
DAY- 03
S -
Fever
Vomiting - 6 episodes since yesterday
Unable to sleep
Slight itching sensation all over the body present
O-
Patient is conscious, coherent, cooperative and well oriented to time, place and person
VITALS
BP- 110/60mm Hg
PR- 94bpm
RR- 20 cpm
Temp - 100.1 F
GRBS- 137 mg/dl
SYSTEMIC EXAMINATION
CVS- S1 S2 heard
RS- BAE present
PA - SOFT NON TENDER
CNS- NAD
A -
Dengue fever NS1 positive with thrombocytopenia (platelets - 65000)
P-
1)INJ. NEOMAL 1gm IV if temp > 102°F
2) TAB DOLO 650mg PO/ TID
3) INJ PAN 40mg IV / OD
4) INJ ZOFER 4 mg TID/ SOS
5) IVF 10 RL DNS NS @ 100 ml/ hr
6) TEMP AND VITALS MONITORING 4th hrly
DAY- 04
S - No complaints
O-
Patient is conscious, coherent, cooperative and well oriented to time, place and person
VITALS :
BP- 110/60mm Hg
PR- 94bpm
RR- 20 cpm
Temp - 97.4 F
GRBS- 111 mg/dl
SYSTEMIC EXAMINATION :
CVS- S1 S2 heard
RS- BAE present
PA - SOFT NON TENDER
CNS- NAD
A -
Dengue fever NS1 positive with thrombocytopenia (platelets - 65000)
P-
1)INJ. NEOMAL 1gm IV if temp > 102°F
2) TAB DOLO 650mg PO/ TID
3) T. PAN 40mg PO/OD
4) T. ZOFER 4 mg TID/BD
5) INJ. FALCIGO 120 mg IV
6) TEMP AND VITALS MONITORING 4th hrly
S - No complaints
O-
Patient is conscious, coherent, cooperative and well oriented to time, place and person
VITALS :
BP- 110/60mm Hg
PR- 94bpm
RR- 20 cpm
Temp - 97.4 F
GRBS- 111 mg/dl
SYSTEMIC EXAMINATION :
CVS- S1 S2 heard
RS- BAE present
PA - SOFT NON TENDER
CNS- NAD
A -
Dengue fever NS1 positive with thrombocytopenia (platelets - 65000)
P-
1)INJ. NEOMAL 1gm IV if temp > 102°F
2) TAB DOLO 650mg PO/ TID
3) T. PAN 40mg PO/OD
4) T. ZOFER 4 mg TID/BD
5) INJ. FALCIGO 120 mg IV
6) TEMP AND VITALS MONITORING 4th hrly
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