40yr male presented with fever

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Case scenario:

40yr old male came with complaints of fever since 2 days with no other complaints. 

He went to outside hospital and on investigation Dengue NS antigen positive and Platelet count of 35000cells/cumm and referred  to here  for further treatment. 

History of presenting illness:

Patient was apparently asymptomatic 2 days back then he developed fever of high grade not associated with chills, of continuous type and relieved on medication, for which he went to local hospital and found Platelets count of 35000cells/cumm and admitted here. No h/o cough ,cold,burning micturition, vomitings, loose stools.

History of past illness:

Not k/c/o HTN,  diabetes mellitus, 

Treatment history:no significant history. 

PERSONAL HISTORY:

Married 

Occupation: labourer

Diet: Mixed , Non vegetarian 

Appetite: Normal

Bowels: Regular 

Known Allergies: No

No addictions.

FAMILY HISTORY:

No significant history. 

General Examination. 

NO  pallor, icterus , cyanosis, clubbing , lymphadenopathy, pedal edema , malnutrition No dehydration 

VITALS:

Temperature-98.6 F

Pulse rate- 

Respiratory rate- 16/min

BP- 100/70mmHg

SPO2 - 98% 

GRBS- 99mg%

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No

RESPIRATORY SYSTEM

Dyspnoea:No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Adventitious sounds : No

ABDOMEN

Shape - Scaphoid 

No tenderness, palpable mass, 

No Fluid 

No bruits

Liver not palpable 

Spleen not palpable. 

Bowel sounds present.

CNS Examination:

Conscious coherent cooperative. 

Speech normal.

No signs of meningitis 

Cranial nerves, motor system, sensory system Normal. 

PROVISIONAL DIAGNOSIS:

DENGUE with NS1 positive  and THROMBOCYTOPENIA.

day2

Day3

Day4

Day5

Treatment

On day1

IVF - normal saline, RL -100ml/hr

Inj. OPTINEURON 1 ampoule 100ml NS IV/OD

Inj.PAN 40mg IV/OD

Inj.ZOFER 4mg IV/SOS

Tab. DOXY 100mg BD

Tab.DOLO 650mgTID

Inj.NEOMOL 1gm IV/SOS.

Strict  I/O charting

repeated hemogram12hrly

Monitor vitals and inform sos.