66 YEAR OLD FEMALE CAME TO THE CASUALITY WITH C/O FEVER, DECREASED APPETITE, NAUSEA AND GIDDINESS SINCE 1 WEEK
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December 14,2021
66 YEAR OLD FEMALE CAME TO THE CASUALITY WITH C/O FEVER, DECREASED APPETITE, NAUSEA AND GIDDINESS SINCE 1 WEEK
66 year old female came to the casuality with
C/O:
- Fever since 1 week- Decreased appetite since 1 week- Nausea since 1 week- Giddiness since 1 week
- Fever since 1 week
- Decreased appetite since 1 week
- Nausea since 1 week
- Giddiness since 1 week
HOPI:
Patient was apparently asymptomatic 1 week back and then she developed fever which was continuous type, relieved on taking medication, not associated with chills and rigors.H/O decreased appetite, nausea and giddiness since 1 weekNo H/O Burning micturition, headache, coldNo H/O Bleeding manifestations
Patient was apparently asymptomatic 1 week back and then she developed fever which was continuous type, relieved on taking medication, not associated with chills and rigors.
H/O decreased appetite, nausea and giddiness since 1 week
No H/O Burning micturition, headache, cold
No H/O Bleeding manifestations
PAST HISTORY:
K/C/O HTN since 1 yearNot a K/C/O DM/Asthma/TB/Epilepsy/CAD/CVD
K/C/O HTN since 1 year
Not a K/C/O DM/Asthma/TB/Epilepsy/CAD/CVD
FAMILY HISTORY:
Not significant.
Not significant.
GENERAL EXAMINATION:
Patient was Conscious,Coherent,CooperativeNo pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema.
Patient was Conscious,Coherent,Cooperative
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema.
VITALS:
Temp. - 98 FPR - 82 bpmRR - 16 cpmBP - 110/70 mmHgSpO2 - 99% @ RA
Temp. - 98 F
PR - 82 bpm
RR - 16 cpm
BP - 110/70 mmHg
SpO2 - 99% @ RA
SYSTEMIC EXAMINATION:
CVS - S1S2 heard, No murmurs
RS - BAE +, Right side IAA Crepts+
CNS - NAD
P/A - Soft, Non tender
INVESTIGATIONS:
Hemogram:
Hb-12.4
TLC- 7, 500
N- 30
L- 66
MCV-77.6
MCH-26.7
RBC - 4.65
PC - 70,000
LFT:
TB-1.10
DB - 0.26
SGOT - 278
SGPT - 213
ALP -390
TP -6.2
A/b- 3.24
A/g -1.09
RFT:
Ur - 39
Cr - 1.2
BGT -A positive.
CHEST X-RAY
ECG
2D ECHO
USG ABDOMEN:
PROVISIONAL DIAGNOSIS:
Viral Pyrexia with Thrombocytopenia secondary to Dengue NS1 Positive with K/C/O Hypertension.
Soap Notes:
S :-
No fresh complaints.
Pain abdomen decreased.
O :-
BP - 140/90 mmhg
PR - 80 bpm
Temp - 98.2F
RR -15cpm
Spo2 - 99% at RA
A :-
VIRAL PYREXIA WITH THROMBOCYTOPENIA SECONDARY TO (DENGUE NS1 POSITIVE) L.KNOWN CASE OF HTN.
P :-
1) IVF NS,RL @ 100ML /HR
2) INJ PAN 40MG IV/OD
3) INJ OPTINEURON 1AMP IN 100ML NS IV/OD OVER 30 MIN
4) PLENTY OF ORAL FLUIDS
5) W/F BLEEDING MANIFESTATIONS
6) INJ ZOFER 4MG IV/SOS
7) TAB DOLO 650MG PO/SOS
8) INJ NEOMOL 1GM IV/SOS
9) BP,PR MONITORING 4TH HOURLY
10) STRICT TEMPERATURE MONITORING 4TH HOURLY.
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