Nanda Kishore Gm case 1
General medicine case 1
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A 33yr old male resident of kattamgur, watchman by occupation came to our hospital with complaints of fever since 5 days, headache since 5 days, left sided chest pain since 3 days and cough since 1 day
He was apparently asymptomatic 5 days back then developed low grade continuous fever which was not associated with chills and rigors, no diurnal variations and relieved on taking medication.
Fever was followed by headache which is diffuse in nature and not associated with nausea or vomiting
He had c/o dry cough not associated with shortness of breath, orthopnea and paroxysymal nocturnal dysnpea and C/o left sided chest pain since 3days which was pricking type and non radiating. Patient had no h/o palpitation, syncopal attacks and burning micturition
There was no any h/o trauma
He is a k/c/o alcoholic and drinks 90ml occasionally and not a smoker
He has no h/o DM, HTN, TB, epilepsy.
There were no similar complaints in the past
On examination patient was conscious, coherent, cooperative and has no Pallor, icterus, cyanosis, clubbing, lymphadenopathy and Edema.
He had no signs of dehydration
He was afebrile with bp of 110/80mmhg, Pulse was 98bpm, Respiratory rate was 22 cpm and his spo2 was 99% on room air and his grbs was 115mg/dl
His systemic examination findings were
CVS - S1, S2 heard and no murmurs
RS - Bilateral air entry present with normal vesicular breath sounds but breath sounds were deceased on auscultating RIA and IAA regions
His abdomin was scapoid in shape with no tenderness, papalable masses, bruits and organomegalies
His CNS examination was normal
Fever charting
Investigations
Hemogram
CUE
RFT
Sr. urea - 51 (increased)
Sr. Creatinine - 1.1 (N)
Sr. Na - 131 (decreased)
Sr. K - 3.9 (N)
Sr. Cl - 97 (slight decrease)
LFT
APTT - 32 sec
BT - 2mins
CT - 4 min 30 sec
SARS COVID 19 - negative
Chest X ray
Serology - negative
Blood grouping and typing - B positive
Patient was positive for ns1 antigen testing
PROVISIONAL DIAGNOSIS - Dengue fever with platelet count of 50000 cells/cumm
TREATMENT
DAY 0
His vitals were
Temperature- 98.6F
BP- 110/70 mmhg
Pulse rate - 80 bpm
Respiratory rate- 16 cpm
GRBS 102mg/dl
Systemic examination was normal
Hb- 17.5
TLC - 5000
Platelet count is 8000
IV Fluids 3NS and 1RL at 100ml/hr with 1 Amp optineurin
- Adviced to take plenty of oral fluids
- TAB. DOLO 650mg/ PO/ SOS
- TAB. DOXCYCILIN 100mg PO/OD
- TAB. PAN 40mg PO/BBF
- Syrup AMBEONLY PO TID 5ml
Day 1
patient had no new complaints
His vitals were
Temperature- 99 F
BP- 110/80 mmhg
Pulse rate - 85 bpm
Respiratory rate- 17 cpm
GRBS 110 mg/dl
Systemic examination was normal
Hb - 17.5
TLC - 5.0
Platelet count is 8000
So patient underwent SGPT after which his platelet counts were 33000
Patient was put on
- IV Fluids 3NS and 1RL at 100ml/hr with 1 Amp optineurin
- Adviced to take plenty of oral fluids
- TAB. DOLO 650mg/ PO/ SOS
- TAB. DOXCYCILIN 100mg PO/OD
- TAB. PAN 40mg PO/BBF
- Syrup AMBEONLY PO TID 5ml
Day 2
patient had no new complaints
His vitals were
Temperature- 98.4F
BP- 110/70 mmhg
Pulse rate - 74 bpm
Respiratory rate- 16 cpm
GRBS 127mg/dl
Systemic examination was normal
Hb - 14 g/dl
TLC - 3.15
PCV - 32.2
Platelet count is 44000
IV Fluids 3NS and 1RL at 100ml/hr with 1 Amp optineurin
- Adviced to take plenty of oral fluids
- TAB. DOLO 650mg/ PO/ SOS
- TAB. DOXCYCILIN 100mg PO/OD
- TAB. PAN 40mg PO/BBF
- Syrup AMBEONLY PO TID 5ml
Day 3
patient had no new complaints
His vitals were
Temperature- 98 F
BP- 110/80 mmhg
Pulse rate - 79 bpm
Respiratory rate- 16 cpm
GRBS 107mg/dl
Systemic examination was normal
Hb - 11.5 g/dl
TLC - 3.37
PCV - 32.2
Platelet count is 75000
IV Fluids 3NS and 1RL at 100ml/hr with 1 Amp optineurin
- Adviced to take plenty of oral fluids
- TAB. DOLO 650mg/ PO/ SOS
- TAB. DOXCYCILIN 100mg PO/OD
- TAB. PAN 40mg PO/BBF
- Syrup AMBEONLY PO TID 5ml
Day 4
patient had no new complaints
His vitals were
Temperature- 98 F
BP- 110/80 mmhg
Pulse rate - 79 bpm
Respiratory rate- 16 cpm
GRBS 107mg/dl
Systemic examination was normal
Hb - 13.7 g/dl
TLC - 4800
PCV - 32.2
Platelet count is 1.5 lakh
IV Fluids 3NS and 1RL at 100ml/hr with 1 Amp optineurin
- Adviced to take plenty of oral fluids
- TAB. DOLO 650mg/ PO/ SOS
- TAB. DOXCYCILIN 100mg PO/OD
- TAB. PAN 40mg PO/BBF
- Syrup AMBEONLY PO TID 5ml
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