22 year male with fever and vomitings
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A 22 year male auto driver by occupation came to opd on 16th june with chief complaints of
•Fever since 15 days
•Vomiting since 12 days
•Yellowish discoloration of eyes since 12 days.
History of presenting illness:-
Patient was apparently asymptomatic 15 days back then he went to work where he comsumed outside food for once per day for 3 days then he developed fever which is continuous , no chills and rigors.
For this he visited local RMP and took medications by which fever got subsided.
3 days later he developed vomitings, 6 to 7 times a day, non bilious, non projectile, food particles as contents, non blood tinged.
Then patient went to a hospital where he was diagnosed with dengue fever.
Past history:
N/k/c/o DM, HTN, CVD, Asthama, Epilepsy, Thyroid problems
No history of similar complaints
No history of any blood transfusions
No history of any previous surgeries
Personal history:
Mixed diet
Adequate sleep
Normal bowel and bladder movements
No addictions (Toddy occasionally)
No allergies
Family history:
Not significant
General examination
Patient is conscious, coherent and cooperative, well oriented to time, place and person
Vitals:
Pulse: 72
Bp: 120/80
Temperature: afebrile
RR: 17
Systemic examination:
CVS- S1 S2 heard no murmurs
CNS- No focal neurological deficit
RS- Normal vesicular sounds heard
PER ABDOMEN:
Inspection
Shape of abdomen-Scaphoid
Umbilicus-inverted,central located
No sinuses or scars on abdomen
Palpation::
No rise in temperature
No Tenderness present
No palpable mass
No free fluid
Liver not palpable
Spleen not palpable
Percussion::
Dull note on right upper quadrant
No fluid thrill
No shifting dullness
Auscultation::
Bowel sound heard
Investigations
ECG
HEPATITIS A VIRUS IGM ANTIBODY--2.86
Normal values(<0.8 -negative;>1.2-positive)
Provisional diagnosis:
Fever with thrombocytopenia Dengue?
Viral hepatitis A?
Treatment
15 /6/23
Rx
1).IV fluids Ns 75ml /hr
2)Inj zofer 4mg iv/tid
3)tab udiliv 300 mg
4)inj optineuron 10 mp 1 ONS/iv
5)syp hepamerz 10 mL iv
6)tab dolo 650 mg sos
16/6/23
Rx
1)IV fluids Ns 75ml /hr
2)Inj zofer 4mg iv/tid
3)tab udiliv 300 mg
4)inj optineuron 10 mp 1 ONS/iv
5)syp hepamerz 10 mL iv
6)tab dolo 650 mg sos
17/6/23
Rx
1)IV fluids Ns 75ml /hr
2)Inj zofer 4mg iv/tid
3)tab odiliv 300 mg
4)inj optineuron 10 mp 1 ONS/iv
5)inj doxy 100mg po/BD
6) tab dolo 650 mg sos
7) syp hepamerz 10 mL iv
8)Syp lactulose 15 mL bd
18/6/23
Rx
1)IV fluids Ns 75ml /hr
2)Inj zofer 4mg iv/tid
3)tab odiliv 300 mg
4)inj optineuron 10 mp 1 ONS/iv
5)inj doxy 100mg po/BD
6) tab dolo 650 mg sos
7)syp hepamerz 10 mL iv
8) Syp lactulose 15 mL bd
19/6/23
Rx
1)IV fluids Ns 75ml /hr
2)Inj zofer 4mg iv/tid
3)tab odiliv 300 mg
4)inj optineuron 10 mp 1 ONS/iv
5)inj doxy 100mg po/BD
6)tab dolo 650 mg sos
7) syp hepamerz 10 mL iv
8)Syp lactulose 15 mL bd
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