A 37 YEAR OLD MALE WITH VIRAL PYREXIA WITH HEPATOMEGALY .
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A 37 year old male came to opd with chief complaints of fever since 5 days ,(cough cold generalized weakness,headache) shortness of breath since 3 days and loose stools since 3 days
HOPI:
Patient was apparently asymptomatic 5 days back then developed high grade fever ,intermittent in nature, associated with chills ,rigor ,generalized body weakness which relieved on taking medication .he also have complaints of cough which is non productive in nature,not associated with expectoration ,no diurnal or positional variation of cough,it is releived on taking cough syrup ,from last 3 days he is experiencing shortness of breath grade 3 according to patient . he also had 5 episodes of loose stools which is non blood stained,non mucoid ,liquid in consistency ,non foul smelling in nature,not associated with abdominal pain and vomitings.
past history: he is not a K/C/O HTN, CAD, epilepsy,asthma ,Tb
personal History:
DIET: Mixed
APPETITE: good
BOWEL AND BLADDER: regular
SLEEP: adequate
ADDICTIONS:alcohol regularly
family history: no significant family history.
GENERAL PHYSICAL EXAMINATION:
patient is conscious ,coherent,cooperative well oriented to time ,place and person,he is a obese and nourished
no signs of pallor, icterus,clubbing ,cyanosis,lymphadenopathy
B/L Pedal edema is present
vitals at the time of admission:
TEMP: 98.9 ° F
BP:110/80 mm Hg
pulse: 110 bpm
RR:22 cpm
per abdominal examination : generalized distension of abdomen,flanks full,all regions move equally with respiration,skin appears normal
umblicus: central and inverted
no visible scars ,sinuses,hernial orifices,pulsation or peristalsis
palpation is done in supine position with limbs flexed, no local rise of temperature or tenderness
liver is palpable
shifting dullness ,fluid thrill could not be elicited
(abdomen is soft ,non tender, with hepatomegaly .)
CVS : S1 and S2 heart sounds heard
CNS: NO focal neurological deficits
RR: BAE Present, normal vesicular breath sounds heard,no adventitious sounds
shape of the chest: normal
trachea appears to be central
small scar is seen on the chest
(reference images taken from navneeth1.blogspot.com)
6/9/22
Diagnosis:
VIRAL PYREXIA WITH THROMBOCYTOPENIA DENGUE NS1 +,hepatomegaly,ascites.
TREATMENT:-
1. IV FLUIDS 10NS with 1amp OPTINEURON
10RS @75ml/hr
2.INJ NEOMOL 1gm/IV/SOS ( If temp >102f)
3.INJ PAN 40 mg /IV/OD/BBF
4.TAB. DOLO 650mg /PO/SOS
5 BP/PR/ TEMP/SPo2 charting 4th hourly
6.Look for postdural drop
7.Inform SOS
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