32 Y/ M with dengue fever with thrombocytopenia

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 32 year old male , construction worker presented to the opd with 

C/O fever since 1 week 

Cough since 1 week 

Cold since 1 week 

Head ache and giddiness since 1 week 

Pt was diagnosed with dengue fever (NS 1 Antigen positive ) 1 week back where he had  

C/O low grade ,intermittent fever with no diurnal variation associated with non productive cough and cold 

Also C/O diffuse headache ,not associated with photophobia or phonophobia 

He C/O giddiness especially on getting up from bed 1 week 

Past history : 

Not a K/C/O DM,HTN,Asthma ,TB,epilepsy 

No similar complaints in the past 

H/ O dog bite in childhood ....then he got 7 sutures infront of right ear ( now , it is like a scar ) ...since then he was not able to hear properly . 

Personal history : 

Married 

Diet - mixed 

Appetite - decreased 

Sleep - adequate 

Bowel movements : regular , Malena + 

Bladder movements : burning micturition +

History of alcohol consumption since 5 yrs,no history of smoking 

O/E:

Pt is conscious,coherent and cooperative 

Vitals: 

Temp : 98.6F

BP: 110/70

PR: 62 bpm

RR: 20

Spo2: 99% on room air

CVS: S1,S2 heard 

RS: BAE +,NVBS 

P/A: soft , NonTender

Bowel sounds heard

 CNS: NAD

Clinical images : 

 

Provisional diagnosis : Dengue Fever with NS1 Antigen positive , with  thrombocytopenia 

Investigations : 

On 25/10/21 

USG ABDOMEN : 

On 26/01/21 

Blood group : B positive 

PLT count : 30,000 

On 27/10/21

PLT count : 60,000 

On 28/10/21 

PLT count : 1.30 lakhs 

Treatment given : 

-IVF NS , RL @ 125 ml/hr 

-INJ PANTOP 40 MG /IV/OD 

-INJ ZOFER 4 MG /IV/SOS 

-TAB DOLO 650 /PO/ SOS

-INJ NEOMOL 100 ML IV / IF TEMP > 101 F 

-SYRUP GRILLINCTUS 10 ML PO/OD /TID WITH 1 GLASS OF WATER 

-TEMP CHARTING 4 TH HRLY , TEPID SPONGING 

-MONITER VITALS 

-POSTURAL BP MONITERING 4 TH HRLY 

-PLENTY OF ORAL FLUIDS . 

SOAP NOTES 

DAY 1 

26/10/21

Fever chart : 

S: Fever spike 

   Cough , cold subsided 

O : Pt is conscious ,coherent, cooperative 

O/E 

PR 82 bpm

BP 90/70 mmHg 

RR 18 cpm

Temp 99.2 F 

GRBS 127 mg/dl

CVS : 

S1 S2 heard , no murmurs 

RS : 

NVBS + 

BAE + 

P/A : 

Soft , non tender 

Bowel sounds + 

CNS : NAD ,HMF INTACT 

A:  Dengue fever with NS1 Antigen positive with thrombocytopenia 

P : 

-IVF NS , RL @ 125 ml/hr 

-INJ PANTOP 40 MG /IV/OD 

-INJ ZOFER 4 MG /IV/SOS 

-TAB DOLO 650 /PO/ SOS

-INJ NEOMOL 100 ML IV / IF TEMP > 101 F 

-SYRUP GRILLINCTUS 10 ML PO/OD /TID WITH 1 GLASS OF WATER 

-TEMP CHARTING 4 TH HRLY , TEPID SPONGING 

-MONITER VITALS 

-POSTURAL BP MONITERING 4 TH HRLY 

-PLENTY OF ORAL FLUIDS . 

SOAP NOTES 

DAY 2

27/10/21

Fever chart : 

S: No Fever spike 

   Cough , cold subsided 

O : Pt is conscious ,coherent, cooperative 

O/E 

PR 84 bpm

BP 110/70 mmHg 

RR 18 cpm

Temp 98.2 F 

GRBS 105 mg/dl

CVS : 

S1 S2 heard , no murmurs 

RS : 

NVBS + 

BAE + 

P/A : 

Soft , non tender 

Bowel sounds + 

CNS : NAD ,HMF INTACT 

A:  Dengue fever with NS1 Antigen positive with thrombocytopenia 

P : 

-IVF NS , RL @ 125 ml/hr 

-INJ PANTOP 40 MG /IV/OD 

-INJ ZOFER 4 MG /IV/SOS 

-TAB DOLO 650 /PO/ SOS

-INJ NEOMOL 100 ML IV / IF TEMP > 101 F 

-SYRUP GRILLINCTUS 10 ML PO/OD /TID WITH 1 GLASS OF WATER 

-TEMP CHARTING 4 TH HRLY , TEPID SPONGING 

-MONITER VITALS 

-POSTURAL BP MONITERING 4 TH HRLY 

-PLENTY OF ORAL FLUIDS . 

SOAP NOTES 

DAY 3 

28/10/21 

Fever chart : 

S: No Fever spike 

   Cough , cold subsided 

O : Pt is conscious ,coherent, cooperative 

O/E 

PR 81bpm

BP 110/70 mmHg 

RR 18 cpm

Temp 98.6 F 

GRBS 93  mg/dl

CVS : 

S1 S2 heard , no murmurs 

RS : 

NVBS + 

BAE + 

P/A : 

Soft , non tender 

Bowel sounds + 

CNS : NAD ,HMF INTACT 

A: Dengue fever with NS1 Antigen positive with thrombocytopenia 

P : 

-IVF NS , RL @ 125 ml/hr 

-INJ PANTOP 40 MG /IV/OD 

-INJ ZOFER 4 MG /IV/SOS 

-TAB DOLO 650 /PO/ SOS

-INJ NEOMOL 100 ML IV / IF TEMP > 101 F 

-SYRUP GRILLINCTUS 10 ML PO/OD /TID WITH 1 GLASS OF WATER 

-TEMP CHARTING 4 TH HRLY , TEPID SPONGING 

-MONITER VITALS 

-POSTURAL BP MONITERING 4 TH HRLY 

-PLENTY OF ORAL FLUIDS .