CASE ON DENGUE


GENERAL MEDICINE
    
Hello all. This is Tejaswi, a third-semester medical student. This e log depicts the patient-centered approach to learning. 

This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Note: This is an ongoing case and will be updated as and when we find new information. 

         This e log is made under the guidance of Dr.Bavya 

 CASE SHEET 

Date of admission:20/8/21


CHIEF COMPLAINT :

Fever high grade associated with chills and rigor 

Generalized weakness and giddiness 

Decreasing trends of platelet counts (60,000 to 45,000 to 17000)

HISTORY OF PRESENT ILLNESS:

The patient presented with fever and chills
 
The onset of fever was from the past 3 days 

The patient feels rotational  while walking, gid

There is generalized weakness 

No hematuria ,Malena ,petiche


HISTORY OF PAST ILLNESS:

1 year back 
He has a history of blood in stools 
Also, his Hb levels  dropped to 7 gm, and had a blood transfusion 

A few months back 
He had yellowish discoloration of sclera,increased bilirubin, and was diagnosed with alcohol liver disease 

1 week back went to the hospital in miryalguda with complaints of fever,tachypnoea 

No history of HTN / DM/TB/Epilepsy


PERSONAL HISTORY 

 His appetite is lost or decreased for the past three days.

 Follows nonveg diet. 

 His bowel habits are regular and his micturition is normal. 

 Has no known allergies

 Habits / addictions 

 He  drinks alcohol  regularly abt 750 ml  per day

 He smokes 2 packets of cigarettes per day 

 
TREATMENT HISTORY

migraine medication used

blood transfusion = one year back 


FAMILY HISTORY :

• Has no family history of DM, HTN, TB, asthma, CAD, strokes, cancers, heart diseases,.

PHYSICAL EXAMINATION:

GENERAL 
  •  Pallor - absent 
  •  icterus - absent
  •  cyanosis - absent
  •  clubbing of fingers/toes - absent
  •  dehydration - mild
  •  lymphadenopathy
  • Oedema - absnet 
  • dehydration mild

VITALS : 

  •  temperature - febrile  - 99.7 
  •  pulse rate - 87bpm
  •  Bp- 100/60 mm Hg
  • RR - 16 cpm
  •  SPO2 - 99%
  • GRBS- 110mg%


SYSTEMIC EXAMINATION :


CENTRAL NERVOUS SYSTEM:

• Pt, conscious, coherent, and cooperative
• Speech is normal
• no signs of meningeal irritation


CARDIOVASCULAR SYSTEM:

• S1, S2 +

RESPIRATORY SYSTEM:

BAE + NVBS

 ABDOMINAL EXAMINATION:

soft,epigastric tenderness  present 
no palpable mass
The free fluid mild amount present
hepatomegaly present 


PROVISIONAL DIAGNOSIS :  

  DENGUE  NS1, THROMBROCYTOPENIA ASSOCIATED WITH  
 ALCOHOLIC LIVER DIEASE 

INVESTIGATIONS :


HAEMOGRAM 

Hb- 16.1gm/dl

total count - 5,400 cells /mm

RBC count - 4.52 million

platelet count - 30,000/cumm

smear

RBC  - normocytic normochromic impression 

WBC- within the normal limits with leucocytosis

platelets reduced 

MCH ,MCHC are elevated 


Serum electrolytes 
 
Na + = 130 mEq/l ( normal  136- 145)

K+ =  3.2 mEq/l ( normal  3.5- 5.5 )

chloride =98-100mEq/l


 RFT 
LFT 

ECG 


CUE 

ULTRASOUND PER ABDOMINAL VEIN 


DENGUE SEROLOGY 

STOOL FOR OCCULT BLOOD \

ACTIVATED PARTIAL THROMBOPLASTIN TIME
PROTHROMBIN TEST 

BLOOD GROUPING AND RH 



FEVER CHART 
\



TREATMENT 

IV FLUIDS  - NS,RL - 150 ml/hr

INJ PANTOP  40 mg IV /OD

INJ ONDONSTERON 4mg IV/SOS

INJ THIAMINE1 AMP IN 100 ml IV/TIO

INJ OPTINEURON IV /OD

T.SPOROLAC- ds


Day 1 

DATE 21/8/21

fever present with chills 
stools passed 
GRBS= 106b 

 platelet count was 35,000/cumm

Pateint conscious ,coherent ,cooperative
PR = 79 bpm
BP 110/70 mmHg
CVS =S1S2+heart sound s
RS = BAE +,NVBS 
P/A= Soft ,epigastric tenderss +
CNS = NFND( no focal neurological deficit )


Day 2 

DATE 22/8/21 

fever still present associated with chills 
stools passed 

chief complaint = epigastric pain 

Pateint conscious ,coherent ,cooperative
PR = 80 bpm
BP =  STANDING = 120/90 mmHg
          SITTING = 130/90 mmHg
CVS =S1S2+heart sound s ,no murmurs 
RS = BAE +,NVBS 
P/A= Soft ,epigastric tenderss +

TREATMENT 

IV FLUIDS  NS,RL, DNS 150  ml/hr 
 INJ PANTOP 40mg IV/OD
INJ OPTINEURON  1amp in 100 ml NS 
INJ THIAMINE 1amp in 100 ml 
ORS 

DAY3 

DATE 23/8/21
 Fever still present with chills 
stools passed 
GRBS =82 
N o chief complaint 

Pateint conscious ,coherent ,cooperative
PR = 78 bpm
BP = 140/90 mmHg
CVS =S1S2+heart sound s ,no murmurs 
RS = BAE +,NVBS 
P/A= Soft ,epigastric tenderss +
CNS = NFND( no focal neurological deficit 


TREATMENT 

IV FLUIDS  NS,RL, DNS 150  ml/hr = contionus infusion 
 INJ PANTOP 40mg IV/OD
INJ OPTINEURON  1amp in 100 ml NS 
INJ THIAMINE 1amp in 100 ml 
ORS 


Day4
 
DATE 24 /8/21


fever still present associated with chills 
stools passed 
 

Pateint conscious ,coherent ,cooperative
PR = 80 bpm
BP = 100/80mmHg
  
STANDING = 110/70 mmHg
          SITTING = 100/80 mmHg

CVS =S1S2+heart sound s,no murmurs 
RS = BAE +,NVBS 
P/A= Soft ,diffuse tenderness 
CNS = NFND( no focal neurological deficit 

PLATELET COUNT INCREASED TO 60,000/cumm

TREATMENT 

IV FLUIDS  NS,RL, DNS 150  ml/hr 
 INJ PANTOP 40mg IV/OD
INJ OPTINEURON  1amp in 100 ml NS 
INJ THIAMINE 1amp in 100 ml 
ORS 
PLENTY OF ORAL FLUIDS 
TAB BENFOMET OD 


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