A 20 YEAR OLD MALE PATIENT:-
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A 2o year male patient daily labourer by occupation came to casuality with chief complaints of fever & headache since yesterday.
HISTORY OF PRESENT ILLNESSES:-
Patient was apparently asymptomatic since yesterday came with compliants of fever around yesterday night ,high grade fever associated with chills & rigor on,off relieved on medication,no history of cold,cough.
History of headache since yesterday,pain in frontal region, throbbing type of pain, during episodes of fever,photophobia +& phonophobia + aggrevating with position variation, lacrimation (-)diplopia(-).
No history of nausea, vomiting,loose stools
No history of chest pain, palpitation,syncopal attacks.
No history of sob,orthopnea, palpitation
No history of pedal edema,facial puffiness
No history of burning micturition.
HISTORY OF PAST ILLNESS:-
No history of similar compliants in the past
Not a known case of DM, HTN,TB,Asthma, epilepsy.
No history of previous surgeries & no history of previous blood transfusions.
PERSONAL HISTORY:-
Diet:- mixed
Appetite:- normal
Bowel movements:- normal
Micturition:- normal
Addictions:-
Not an alcoholic
No smoking
FAMILY HISTORY:-
There are no similar compliants in the family members.
VITALS:-
pulse rate:- 84BPM
RR:- 18 CPM
Bp:-90/60 mm of Hg
SpO2:-99%at RA
GRBS:- 99mg/dl
TREATMENT HISTORY:-
- He is not a known case of any drug allergy.
GENERAL EXAMINATION:-
Patient is conscious, coherent, cooperative at the time of joining.
Patient is thin built & malnourished.
- no pallor
- no icterus
- no cyanosis
-no clubbing of fingers and toes
- no lymphadenopathy
- no pedal edema
SYSTEMIC EXAMINATION:-
CVS:-S1& S2 heard,no murmurs
RS:- position of trachea :- central
BAE:+
NVBS heard
P/A :- soft ,non tender, no palpable masses or swelling.
CNS :- NAD.
DIAGNOSIS:-
Dengue
ECG:-
Fever chart :-
Hemogram
Dengue antigen test
ESR:-
Malaria parasite:-
CUE:-
Serum protein:-
SGPT:-
SGOT:-
SERUM BILIRUBIN:-
SERUM CREATININE:-
SEROLOGY:-
Diagnosis:- Dengue
Treatment given:-
1)IV fluids
2)tab pcm 650mg po/tid
3)Inj neomol 1h/iv/sos
4)Inj pan 40mg/po/od
5)Inj zofer 4mg iv/ sos
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