22 YEARS OLD MALE WITH DENGUE FEVER

​A 22 year old male came with complaints of Fever with chills,Headache ,Lower back pain,Generalised body pains,Cough with expectoration since 5 days.

HOPI:

Patient was apparently asymptomatic 5days back and then developed fever associated with chills (high grade) intermittent with evening rise in temperature associated with headache(frontal) and cough which is productive (white colour) and generalised body pains.

PAST HISTORY:

Not a K/C/O DM, HTN, TB,EPILEPSY, ASTHMA

PERSONAL HISTORY:

He is Single and Car driver by occupation.
He consumes 
  • Mixed diet 
  • sleep is adequate 
  • Appetite normal
  • bowel and bladder movements are regular
  • He used to Consume Alcohol occasionally.
FAMILY HISTORY: no similar complaints in the family.

GENERAL EXAMINATION:
Patient is conscious , coherent and cooperative and well oriented to time place 
and person, 

Moderately built and moderately nourished.

VITALS:

BP: 120/80mmhg
PR: 84
RR: 18
Temp: 99.5f

SYSTEMIC EXAMINATION:

RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: not tender
CNS: NAD


INVESTIGATIONS:

26/8/22







27/08/2022



28/08/22

Provisional diagnosis: dengue fever.
TREATMENT:

1. IV fluids 2 NS 2 RL @75ml/hr
2. Inj.Neomol 1gm/iv/sos (if temp>102f)
3. Tab.DOLO 650mg/PO/SOS
4. SYP. Ascoril-LS 15ml/PO/TID
5. Temp charting 4th hrly 
6. Monitor vitals inform SOS

27/08/2022
Day 2

S: fever with chills, backpain, headache,cough with expectoration since 5 days.

O: pt is conscious, coherent,cooperative.
BP: 110/80mmhg
PR: 84
RR: 18
Temp: 99f
RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: not tender
CNS:NAD

A: DENGUE FEVER

P:
1. IV fluids 2 NS 2 RL @75ml/hr
2. Inj.Neomol 1gm/iv/sos (if temp>102f)
3. Tab.DOLO 650mg/PO/SOS
4. SYP. Ascoril-LS 15ml/PO/TID
5. Temp charting 4th hrly 
6. Monitor vitals inform SOS


28/08/22
Day 3

S: fever with chills, backpain, headache,cough with expectoration since 5days.
Presently severe back pain since night

O: pt is conscious, coherent,cooperative.
BP: 120/80mmhg
PR: 96
RR: 20
Temp: 99f
RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: not tender
CNS:NAD

A: DENGUE FEVER

P:
1. IV fluids 2 NS 2 RL @75ml/hr
2. Inj.Neomol 1gm/iv/sos (if temp>102f)
3. Tab.DOLO 650mg/PO/SOS
4. SYP. Ascoril-LS 15ml/PO/TID
5. Temp charting 4th hrly 
6. Monitor vitals inform SOS
7.Tab.Ultracet 1/2 QID

29/08/22
Day 4

S: fever with chills, backpain, headache,cough with expectoration since 5days.
back pain relieved 

O: pt is conscious, coherent,cooperative.
BP: 120/80mmhg
PR: 100
RR: 20
Temp: Afebrile
RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: not tender
CNS:NAD

A: DENGUE FEVER

P:
1. IV fluids 2 NS 2 RL @75ml/hr
2. Inj.Neomol 1gm/iv/sos (if temp>102f)
3. Tab.DOLO 650mg/PO/SOS
4. SYP. Ascoril-LS 15ml/PO/TID
5. Temp charting 4th hrly 
6. Monitor vitals inform SOS
7. Tab.Ultracet 1/2 QID

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