A 14 yrs old male presented to opd on 7 sep ,2021 with chief complain of fever since 1 week 

      History of present illness:

- [ ] Patient was apparently well one week back. Patient complaints of fever since 1 week. Patient is suffering with tightness in abdomen .

- [ ] Patient undergone one episode of vomiting.

- [ ] They is also a history of loose stool(black coloured stool) with generalized weekness.

- [ ] Patient even complains of ear pain .and they is no history of cough ,no ear discharge,no ear trauma,no nasal obstruction 

- [ ] They is no history of ringing sensation 

- [ ] Patient even complaints of breathlessness

     History of past illness:

         Not a known case of CAD,asthma,TB, epilepsy,thyroid disorder

       They is no history of blood transfusion in the past

      Not a known case of hypertension 


Personal history:

1. Diet:mixed

2. Loss of appetite -present 

3. Bowel and bladder movement-irregular 

4. Respiration-normal

5. Sleep -regular.

Allergy history:

Patient is not allergy to any known food ,dust or pollen

General examination:

1.Patient is conscious,coherent and cooperative 

2.no history of cubbing, no cyanosis, no swelling 

3.no lymphonopathy

4. Thrombophlebitis is positive 

5.no malnutrition 

6 . Mild dehydration


Vitals-

1 . temp -98.4 *F 

2.  Pulse rate- 96 beats / min

3. Respiratory rate-16/min

4.BP-100/ 70 mm/hg

5. Spo2- 98%

6. GRBS - 107mg /%


Systemic examination:

   1-CVS: cardiac sounds-s1,s2 is positive 

        - no murmurs and no trills 

  2- respiratory system:

        -absent of dyspnoea

        - no wheeze and position of trachea is central

        - breath sound - vesicular

3-ABDOMEN:

     Shape of abdomen-scaphoid 

     No tenderness and no palpable mass

     Hernial orifice is absent 

     Liver is not palpable 

     Bowel sounds are present.


4- CNS: 

   Patient is conscious 

   Speech is normal 

   No neck stiffness 

   No kerning’s sign.

INVESTIGATION:

Hemogram:

BLOOD UREA:

Serum creatinine:  


Fever chart:

ECG:

Complete urine examination:


Dengue NS1 antigen:
HBsAg-rapid :


Serum electrolyte:

Serum creatinine:


Provisional diagnosis: 
  Dengue antigen NS 1 is detected

Treatment:   

1.IVF-Ns
     -RL
    - 100Ns
   75 ml /hr
2.inj pan 40 mg/IV /OD
3.inj zofer-4mg /Iv/sos
4.soft oral diet 
5.plenty of oral fluids
6.T.buscopan-po/oD
7.T.PCM 650 mg/po/sos
8.monitor vitals










 


 


 


 

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