Case Discussion: Dengue

 27/10/2021

Samhita Ghanathay

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34 year old male with complaints of Fever and Cold. 

I've been given this case to solve, in an attempt to understand the topic of "patient clinical data analysis" to develope my competency  in reading and comprehending clinical data - including history, clinical findings, investigations - and come up with diagnosis and treatment plan.

Following is a brief about the case,

(History as per date of admission).

CHIEF COMPLAINTS:

A 32 year old gentleman, laborer by occupation and resident of Bhuvanagiri came to the Medicine OPD with chief complaints of: 

• Fever since 1 week

• Cough and cold since 1 week

• Headache since 1 week

• Body pains since 1 week

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 1 week ago when he developed: 

Fever of sudden onset, gradually progressing to high grades of temperature (actual values not available).It was continuous in nature. It was associated with headache and body pains but not associated with chills and rigor.

On visiting a local doctor, he was suspected to have typhoid and was prescribed medications accordingly - but the fever did not regress. There were no aggrevating factors. 

He also developed dry cough that worsened on taking above medications, after which they were referred to our hospital.

HISTORY OF PAST ILLNESS: 

     • He is not a known case of Hypertension, Diabetes Mellitus, Asthama, Epilepsy, or TB.

     • He has no history of any surgeries in the past.

     • He has no history of similar complaints in the past.

PERSONAL HISTORY:

• Diet - Mixed

• Appetite - Reduced

• Bowel and Bladder - Regular

• Sleep - Disturbed

• No known allergies

• No addictions

FAMILY HISTORY:

No history of similar complaints in the family.

GENERAL EXAMINATION:

The patient is conscious,coherent and cooperative; well oriented to time,place and person.

He is sitting comfortably on the bed.

He is moderately build and well nourished.

• Pallor-absent 

• Icterus-absent

• Clubbing-absent

• Cyanosis-absent

• Lymphadenopathy-absent

• Edema - absent

Vitals: 

• Temperature - 99* F

• Pulse rate - 90/ minute 

• Respiratory rate - 20/minute

• Blood pressure (left arm) - 120/70 mm of Hg

• SpO2 (At room air) - 98% 

• GRBS - Normal.

SYSTEMIC EXAMINATION:

CVS: S1 and S2 heard. No addded thrills or murmurs heard

RESPIRATORY SYSTEM:  

Normal vesicular breath sounds heard. 

ABDOMEN:

Soft and non-tender.

No organomegaly seen

CNS:

Conscious and coherent.

Normal sensory and motor responses.

INVESTIGATIONS:

 

Investigations ordered: CBP and CUE

CPB: Lymphocytosis and Thrombocytopenia seen.

CUE : Normal.

Fever chart : 

PROVISIONAL DIAGNOSIS: 

Dengue Fever associated with Thrombocytopenia.

TREATMENT:

25/10/2021 (Day 1) and 26/10/2021 (Day 2):

• Inj. Pantop - 40mg IV OD

• Inj. Neomol - 100ml IV SOS

• Tab. Dolo - 650mg P/O SOS 

• Grilinctus syrup - 10ml P/O TID

• IV NS 125ml/hr

• IV RL 125ml/hr

27/10/2021 (Day 3): 

• IV NS 100ml/hr

• IV RL 100ml/hr

• Inj. Zofer- 4mg IV SOS

Pantop, Dolo, Grylinctus are continued as before. 

NOTES:

• Patient came to the hospital on 7th day of symptoms and was admitted on the same day.

• Duration of Hospital stay: 4 days

• Reason for discharge: Fever and other symptoms reduced. Patient was healthy.

• Severity of disease : Mild.