14 yr old male patient with dengue fever

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.


CHIEF COMPLAINTS:-

A 14 yr old male patient came to opd with fever  and chills , cough with sputum since 5 days.

History of Present ILLNESS:-

The patient was apparently asymptomatic 5 days back.Then he developed fever associated with chills.

Cough associated with sputum since 5 days.

There is history of vomiting 1 episode 3 days back which was non projectile and non bilious.

No h/o pedal edema.

No h/o decreased urine output,s/o/b, palpitations.

No h/o chest pain and abdominal pain.


PAST HISTORY:-

No history of such illness in the past.

Not a k/c/o diabetes, hypertension,asthama or epilepsy.


PERSONAL HISTORY:-

Mixed diet.

Adequate sleep .

Moderately built and we'll nourished.

Decreased appetite.

Bowel and bladder movements are regular.


GENERAL EXAMINATION:-

Temp:98F

PR:90/min.

BP:100/80 mm Hg

SpO2:98%

No pallor.

No cyanosis.

No clubbing.

No lymphadenopathy.

Not malnourished.

Mild dehydration.

No icterus .

No h/o oedema .


SYSTEMIC EXAMINATION:-

Cvs: S1 and S2 heard.

        No cardiac murmurs.

Respiratory : Position of trachea is central.

                         Vesicular breathing.

                         No dyspnoea and wheezing.

                          BAE is positive.

Per Abdomen: Shape of abdomen -scaphoid.

                            No abdominal tenderness.

                            No palpable mass.

                            Bowel sounds are heard.

                            No abdominal free fluid.

                            Liver and spleen not                                              palpable .

CNS: Conscious 

          Speech - normal.

          No signs of meningeal irritation.

          Gait is normal.


PROVISIONAL DIAGNOSIS :-

Viral Pyrexia Under Evaluation.


INVESTIGATIONS:-

1.Cbp:-








2.Urine examination:-


3.ECG:-



Ns1 antigen positive.


FINAL DIAGNOSIS:-

Dengue fever.


TREATMENT:-

IVF - normal saline ,Ringer lactate at 75ml/ hr.

Tab Augmentin- 625mg PO/BD

Tab Dolo- 650mg Po/TID

Inj PAN 40mg PO/OD

Inj OPTINEURON 1 AMP. In 100 ml NS/IV /OD

Inform SOS.
















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