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A 19 YR OLD FEMALE

Unit 6 admission 

A 19 yr old female, student by occupation & resident of Nagarjun sagar .came to casualty with 

COMPLAINTS OF 

1.Fever since 3 days
2.Vomitings 5 episodes since 1 day
3.Stomach pain since 1 day
4.Loose stools 2 episodes since 1 day
5. Cough with expectorantion since 1 day

HISTORY OF PRESENT ILLNESS  :

1.FEVER

- 3 days back she had
-  Insidious onset of fever, low grade, intermittent type, Relieved on taking medications.subsided with in a day
- Not associated with chills and Rigors.

2.VOMITINGS:

- 5 episodes/ day since 1 day
- non projectile,non bilious, contain food particles initially & later watery

3.STOMACH PAIN :

- Diffuse type,increased after vomiting episode

4.LOOSE STOOLS :

- 2 episodes/day
- small inquantity
- Not associated with pain abdomen, bloody stools -ve,Tenesmus -ve

5.COUGH WITH EXPECTORATION :

- expectoration - small in quantity, light green color 
- cough is not associated with diurnal variations,cough is more in rt lateral position 
- not associated with night sweats,weight loss,blood tinge

PAST HISTORY :

- Got tested positive for rapid dengue test 4 days back, near local hospital

- Had complaints of cough with expectoration15 days back,for which she used medications for 3 days & cough got subsided
- Again cough increased from yesterday after fluid administration 

- Rt side lump in breast operation done 1 yr back
- Appendix operation done - 18 months back
- No similar complaints in past 
- n/k/c/o DM,HTN,Asthma,epilepsy,Thyroid

FAMILY HISTORY:

- Mother also got tested positive for rapid dengue test 4 days back 

PERSONAL HISTORY:

- Diet - mixed
- Appetite -  normal
- Sleep- adequate 
- Bowel & Bladder movements - increased 
- no cigarette & alcohol habits

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative. 
No pallor 
No icterus 
No clubbing, cyanosis 
No koilonychia
No lymphadenopathy
No Edema 

VITALS :

1.Temperature : Afebrile 
2. BP : Supine - 100/70mmHg
           : Standing - 100/80 mmHg
3. PR : 66 bpm
4. RR : 18cpm

SYSTEMIC EXAMINATION :

PER ABDOMEN:

- No distended abdomen
- abdominal tenderness - present 
- No engorged veins
- Gaurding & rigidity present

RESPIRATORY SYSTEM:
-Trachea central in position 
-BAE+ 
-NVBS 

CVS :
- S1S2 HEARD 
-no thrills no murmurs

CNS:
- All superficial and deep reflexes are normal

PROVISIONAL DIAGNOSIS :

- Dengue NS 1 antigen + 
- Viral pyrexia with thrombocytopenia 
- Suggestive of Dengue

INVESTIGATIONS :

HEMOGRAM:

6 DAYS BACK:
- TOTAL WBC COUNT: 6,700 cells/cumm
- PLATELET COUNT: 2.33 lakhs/cumm
- PCV : 34.5%

5 DAYS BACK:
- TOTAL WBC COUNT: 7,500 cells/cumm
- PLATELET COUNT: 2.24 lakhs/cumm
- PCV: 37.1%

4 DAYS BACK:
- TOTAL WBC COUNT:11,300cells/cumm 
- PLATELET COUNT: 1.41 lakhs/cumm
- PCV: 35.2%

3 DAYS BACK:
- PLATELET COUNT: 0.31 lakhs/cumm 

2 DAYS BACK:
Afternoon -
- TOTAL WBC COUNT: 7,200 cells/cumm
- PLATELET COUNT : 56,000/cumm
- PCV: 39.7%

Night -
- TOTAL WBC COUNT: 5,200cells/cumm
- PLATELET COUNT: 50,000/cumm
- PCV: 37.1%

1 DAY BACK:
- TOTAL WBC COUNT: 8,200cells/cumm
- PLATELET COUNT: 35,000/cumm
- PCV: 40.6%

TODAY:
- TOTAL WBC COUNT: 9,600cells/cumm
- PLATELET COUNT: 39,000/cumm
- PCV: 37.2%

BLOOD  GROUP:
DENGUE RAPID TEST:

MALARIAL PARASITE TEST:
SEROLOGY : NEGATIVE 
RTPCR : NEGATIVE 
RBS: 

LFT :

CUE:
BLOOD UREA:
SERUM CREATININE :

SERUM ELECTROLYTES:
USG:
ECG:

TREATMENT:

ON 28/8/21

1. IVF NS, RL @ 150ml/hr
2. TAB DOLO 650 mg/PO/OD
            1------1-----1
3. INJ PANTOP 40MG/IV/BD
            1-------1------1
4. INJ ZOFER 4MG/IV/SOS
5. WATCH FOR BLEEDING MANIFESTATIONS 
6. POSTIRAL BP MONITORING 
7. SYRUP TUSQ DS 15ml/PO/TID

ON 29/8/21

1.IVF NS, RL @ 150ml/hr
2. TAB DOLO 650 mg/PO/OD
            1------1-----1
3. INJ PANTOP 40MG/IV/BD
            1-------1------1
4. INJ ZOFER 4MG/IV/SOS
5. WATCH FOR BLEEDING MANIFESTATIONS 
6. POSTIRAL BP MONITORING 
7. SYRUP TUSQ DS 15ml/PO/TID

ON 30/8/21

1.IVF NS, RL @ 150ml/hr
2. TAB DOLO 650 mg/PO/OD
            1------1-----1
3. INJ PANTOP 40MG/IV/BD
            1-------1------1
4. INJ ZOFER 4MG/IV/SOS
5. WATCH FOR BLEEDING MANIFESTATIONS 
6. POSTIRAL BP MONITORING 
7. SYRUP TUSQ DS 15ml/PO/TID

FEVER CHART:
SOAP NOTES:
ON 28/8/21

SUBJECTIVE:
1. Fever present
2. Vomitings 5 episodes/day
3. Loose stools 2 episodes/day
4. Cough with expectoration 

OBJECTIVE:
1.Temperature - 99.2°F
2.BP - 110/70 mmHg
3.PR - 72bpm

ASSESSMENT:
1.Fever with thrombocytopenia 

PLAN OF CARE:

1. IVF NS, RL @ 150ml/hr
2. TAB DOLO 650 mg/PO/OD
            1------1-----1
3. INJ PANTOP 40MG/IV/BD
            1-------1------1
4. INJ ZOFER 4MG/IV/SOS
5. WATCH FOR BLEEDING MANIFESTATIONS 
6. POSTURAL BP MONITORING 
7. SYRUP TUSQ DS 15ml/PO/TID

ON 29/8/21

SUBJECTIVE:
1. No fresh complaints 

OBJECTIVE:
1.Temperature: 100.5°F
2.BP:Supine - 110/70mmHg
          Standing - 100/70mmHg
3.PR:74bpm

ASSESSMENT:
1.Fever with thrombocytopenia with serositis

PLAN OF CARE:

1. IVF NS, RL @ 150ml/hr
2. TAB DOLO 650 mg/PO/OD
            1------1-----1
3. INJ PANTOP 40MG/IV/BD
            1-------1------1
4. INJ ZOFER 4MG/IV/SOS
5. WATCH FOR BLEEDING MANIFESTATIONS 
6. POSTURAL BP MONITORING 
7. SYRUP TUSQ DS 15ml/PO/TID

ON 30/8/21

SUBJECTIVE:
1.No fever spikes

OBJECTIVE:
1.Temperature -
2.BP:Supine - 110/70mmHg
          Standing - 100/70mmHg
3.PR - 76bpm

ASSESSMENT:
1.Fever with thrombocytopenia with serositis

PLAN OF CARE:
1.IVF NS,RL @ 150ml/Hr
2.TAB DOLO 650 mg/PO/OD
            1------1-----1
3. INJ PANTOP 40MG/IV/BD
            1-------1------1
4. INJ ZOFER 4MG/IV/SOS
5. WATCH FOR BLEEDING MANIFESTATIONS 
6. POSTURAL BP MONITORING 
7. SYRUP TUSQ DS 15ml/PO/TID






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