General medicine case 1

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Date of admission:-8/12/2021 

Cheif complaint:-

A 13 year old male who is a student by occupation presented to opd with a cheif complaint of 

Fever since 3days

Cough since 4days 

Loose stools since 3days 

Vomitings since 4days 

Giddiness since 4days 

History of present illness:-

 Daily routine of a patient:-

Patient wakes up a 7am in the morning takes his breakfast and reaches the school by 9am. Then he attends his school from 9-5 and reaches home by 5:30pm.He completes  his homework and goes out for play then takes his dinner and go to bed by 9pm

Patient was asymotomatic 5days back but suddenly he had a high grade fever which is intermittent associated with chills,with vomiting 4-5 episodes per day since 3days,dry cough and also giddiness since 3days 

Before 5days when he has fever then he visited the local hospital where they did several diagnosis and confirmed that he has low platelet count then he immediately visited our hospital 3days. 

Past history:

He had no similar complaints in the past. 

 No h/o diabetes 

No h/o epilepsy

No h/o TB

No h/ asthma 

No history of any previous surgery in the past. 

Personal history:

Appetite:abnormal 

Diet:mixed 

Sleep-inadequate 

Bowel-loose stools

bladder movements :normal 

No addictions 

Family history:

No similar complaints in the family. 

Drug history:

No allergy to known drugs 

General examination:

 Patient is conscious,coherent, cooperative. 

No Pallor

No cyanosis 

No lymphadenopathy 

No clubbing 

No icterus 

No edema

No tremors 

Vitals 

Temperature : 98.3F

Pulse rate:-72 bpm

Bp:-90/50mm/hg

Respiratory rate:-18cpm

Systemic examination:- 

 Cvs 

 S1 and s2 are heard .

 Respiratory system 

No dysponea 

Position of trachea central .

Abdomen:

Soft and non tender  

CNS

Patient is conscious 

Speech is normal 

Investigations:-

Fever chart:-

Provisional diagnosis:-

Dengue with thrombocytopenia 

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 GRILINCTUS LS 10 ml PO BD

12. Syp POTCHLOR 10 ml in glass of water PO BD