GENERAL MEDICINE CASE-7
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13 YEAR OLD BOY COMPLAINTS OF HIGH GRADE FEVER SINCE 4 DAYS
A 13 year old school going boy complaints of
- high grade fever since 4 days
- vomitings since 4 days
-dizziness since 4 days
- loose stools since 1 day
Patient was apparently asymptomatic 4 days back then he developed fever associated with chills
Complaints of vomiting since 4 days,2-3 episodes/day with food particles as content
Loose stools- 5 episodes in the past one day
No history of burning micturition, melena, rashes, bleeding gums, hematuria
VITALS
Temp- 98.8 F
PR- 90 bpm
BP- 100/60 mmHg
RR- 18 cpm
Spo2- 98% at RA
GRBS- 118mg%
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative.
No signs of Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy or Edema.No signs of Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy or Edema.
SYSTEMIC EXAMINATION
CVS: S1 S2 heard, no murmurs/thrills
RS: position of trachea-central
Abdomen:Soft, non tender. Liver and Spleen not palpable. Bowel sounds heard.
CNS: coordinated
PROVISIONAL DIAGNOSIS
NS 1 + DENGUE
INVESTIGATIONS
Platelets- 1,02,000 lakhs/cu.mm
On 8/12/21
Hb- 15.6 mg/dl
TLC- 2,300
PLT- 45,000
BGT- AB POSITIVE
BLOOD MALARIAL PARASITE- NEGATIVE
RBS- 110 mg/dl
DENGUE NS1 +
Serum electrolytes:
Serum Urea- 13mg/dl
Serum Creatinine- 0.6micromoles/lit
Na- 135mEq/lit
K- 3.0
Cl- 96
LFT:
Total Bilirubin- 0.40mg/dl
Direct Bilirubin- 0.18mg/dl
AST- 10
ALT- 9
ALP- 110
TP- 4.0
ALB- 2.0
A/G- 1.0
USG ABDOMEN
ECG
CHEST XRAY
TREATMENT
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