A 38 YEAR OLD MALE WITH COMPLAINTS OF HIGH GRADE FEVER

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This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs available global online community of experts with the aim to solve the patient's clinical problems with the collective current best evidence based inputs. This E-log book also reflects my patient centred online learning portfolio and your valuable inputs in the comments section.

38 YEAR OLD MALE COMPLAINTS OF HIGH GRADE FEVER SINCE 5 DAYS

A 38 year old male, private employee, complaints of 

- high grade fever since 5 days

- productive cough since 3 days

- shortness of breath since 3 days

- vomitings since 3 days

- loose stools since 1 day

Patient was apparently asymptomatic 5 days ago after which he developed high grade fever with chills- intermittent, subsided at the time of admission. 

Complaints of productive cough associated with shortness of breath on and off since 3 days. No complaints of orthopnea, pedal edema. 

Vomitings since 3 days- 2-3 episodes per days with food particles as content. 

Loose stools since 1 day- 10-15 episodes, watery consistency, two episodes of black coloured stools. 

Complaints of burning micturition 2 days ago, lasted for one day and then subsided. Generalised body pains+

No complaints of bleeding gums, rashes, hematemesis

No complaints of pain abdomen or abdominal distension

PAST HISTORY

History of SARS COVID in May 2021- admitted and relieved. 

Patient isn't a diabetic, hypertensive, no cardiac problems, never been diagnosed with TB. 

VITALS

Temp- 98.6 F

PR- 98 bpm

BP- 120/90 mmHg 

RR- 22 cpm

Spo2- 98% at RA

GENERAL EXAMINATION

Patient is conscious, coherent and cooperative. 
No signs of Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy or Edema.

 




SYSTEMIC EXAMINATION

CVS: S1 S2 heard, no murmurs/thrills

RS: BAE+, NVBS heard

PA: Soft, non tender. Liver and Spleen not palpable. Bowel sounds heard.

CNS: NFND

PROVISIONAL DIAGNOSIS

Dengue NS1+ 

INVESTIGATIONS

Outside Reports:

NS1+

Platelets- 62,000 lakhs/cu.mm

8/12/21 

Hb- 16.7 mg/dl
TLC- 9600
PLT- 40,000
Hct- 47.9

ABG

pH- 7.469
pCO2- 22.7
pO2- 90.9
HCO3- 16.3

RBS- 90 mg/dl

Serum Urea- 20
Serum Creatinine- 1.0
Na- 142
K- 4.1
Cl- 100

Total Bilirubin- 1.16
Direct Bilirubin- 0.25
AST- 346
ALT-133
ALP- 211
TP- 5.6
ALB- 3.33
A/G- 1.47

USG ABDOMEN


ECG


CHEST XRAY



TREATMENT

1. IVF NS, RL, DNS @100ml/hr continuous
2. Inj PANTOP 40 mg IV OF
3. Plenty of oral fluids
4. Inj ZOFER 4mg IV TID
5. W/F Bleeding manifestations, postural hypotension
6. ORS sachets in 1 litre of water, 200 ml after each stool
7. Tab DOLO 650 mg PO SOS
8. Inj NEOMOL 1g IV SOS (if temp>101.1 F) 
9. Temp chatting fourth hourly
10. BP/PR chatting fourth hourly
11. Syp ASCORIL LS 10 ml PO BD

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