56 year old male patient with dengue fever
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A 56 year old male patient presented to the opd with fever since 10 days.
History of present illness
Patient was apparently asymptomatic 10 days back. Then he developed fever which was continues , decreasing after taking anti pyretics and again increasing.
Patient went to local hospital , then also fever did not subside so came to the KIMS.
Fever is insidious in onset, no diurnal variation.
Fever is not associated with chills or headache.
History of decreased urine output since 3days.
Past history
There is no history of diabetes, hypertension, TB, epilepsy
There is no history of any major surgeries.
Personal history
Patient consumes mixed diet.
Loss of appetite
Regular bowel movements. Decreases urine output.
Sleep is adequate.
Patient is alcoholic since 30 years consumes occasionally.
No smoking.
Treatment history
No similar complaints in the past.
No history of any drug allergy.
General examination.
Patient is concisous, coherent and co operative.
Well oriented to the place, time and person. Well nourished.
No Vomitings
No bilateral pedal edema
No pallor
No clubbing
No cyanosis
No icterus
No generalised lymphedenopathy.
Vitals
Temperature:98.6°f
Pulse rate:92beats/min
B. P:110/70mm hg
Respiratory rate:16cycles/min
SPo2:98%
GRBS:128mg%
Systemic examination
Cardiovascular
S1, S2 heard.
No murmurs
Respiratory system
Bilateral airway +
Position of trachea: central
Normal vesicular breath sounds+
No crepts.
Per abdomen
Shape of abdomen:scaphoid
Tenderness is not present.
No palpable mass.
Liver and spleen not palpable.
Bowel sounds heard.
Central nervous system
Patient is concisous
Speech is normal
Reflexes are normal.
INVESTIGATIONS
ECG
HEMOGRAM
On 7th november
Haemoglobin:14.1gm/dl
Total cells:4,500cells/cumm
Neutrophils:50%
Lymphocytes:40%
Eosinophils:02%
Monocytes:08%
Basophils:0%
RBC:4.17millions/cumm
Platelet : 90,000/cumm
On 8th November
Haemoglobin:13.4gm/dl
Total cells:4,300cells/cumm
Neutrophils:43%
Lymphocytes:42%
Eosinophils:05%
Monocytes:10%
Basophils:0%
RBC:3.95millions/cumm
Platelet : 90,000/cumm
Smear: normocytic normochromic blood picture with thrombocytopenia.
URINE EXAMINATION
Colour:pale yellow
Appearance:clear
Reaction:acidic
Sp. Gravity:1.010
Album in:++
Sugar:nil
Bile salts:nil
Bile pigments:nil
Pus cells:3-6
Red blood cells:nil
Epithelial cells:2-3.
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