55 Y/F with fever and generalised weakness

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CHIEF COMPLAINTS: 

Fever since 10 days

Generalised weakness since 8 days

Shortness of breath since 6 days

HOPI :

Patient was apparently asymptomatic 10 days back, then she developed fever which is of high grade , intermittent, associated with chills and rigor, no diurnal variation and relieved with medication. Generalized weakness and fatigue since 8 days. Shortnes of breath since 6 days, no orthopnea, chest pain, palpitations, giddiness. Pedal edema present

No H/O cold , cough , vomitings, 

PAST HISTORY:

Not a k/c/o DM , HTN , epilepsy, asthma , CAD , CVD,TB

PERSONAL HISTORY:

Appetite-Decreased 

Diet - Mixed

Bowel and bladder - regular 

Sleep - Decreased.

General examination:

Patient is conscious, coherent, cooperative, well oriented to time , place and person 

Pallor - present

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy- absent 

Pedal edema - pitting type extending till knee 

VITALS :  Temp - 98.6 F

                  PR - 62 bpm

                 BP - 80/50 mmhg

                RR - 32 cpm

                SPO2 - 98% onRA

                GRBS - 102 mg/dl

Systemic examination: 

PER ABDOMEN:

Inspection :

Umbilicus is central and inverted

All quadrants are moving equally with respiration 

No scars , sinuses , engorged veins, visible pulsations .

Hernial orifices are free.

Palpitation :

Abdomen is soft and tenderness present in right hypochondrium

No organomegaly.

Percussion :

Tympanic note heard over the abdomen.

Auscultation:

Bowel sounds are heard.

CARDIOVASCULAR SYSTEM:

Inspection:

        Shape of chest is elliptical.

        No raised JVP

        No visible pulsations, scars , sinuses , engorged veins.

Palpitation:

        Apex beat - felt at left 5th intercostal space

        No thrills and parasternal heaves

Auscultation :

        S1 and S2 heard. 

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes    Right    Left

Biceps         ++         ++

Triceps        ++         ++

Supinator    ++       ++

Knee            ++       ++

Ankle           ++        ++

PROVISIONAL DIAGNOSIS:

DENGUE SHOCK SYNDROME WITH THROMBOCYTOPENIA WITH PRE RENAL AKI WITH ACUTE LIVER INURY.

1/1/2023 ( DAY 2)

GM UNIT 6

ICU BED 4

S - 

NO FEVER SPIKES

O-

PULSE - 84bpm 

BP -90/60 mmhg on norad 6ml/hr

RR - 28 CPM

SPO2- 98% AT RA

 100% on 4l o2

TEMP - AFEBRILE

CVS - S1 , S2 +

RS - BAE + , NVBS

PA - SOFT , NT.

         NO ORGANOMEGALY 

CNS - NAD

A- 

DENGUE FEVER WITH THROMBOCYTOPENIA WITH AKI ( NON OLIGURIC) WITH ACUTE LIVER INJURY 

DENGUE SHOCK SYNDROME 

P-

IVF - NS WITH 1 AMPOULE OF OPTINEURON 

IVF NS @ 150 ml /hour, 1 DNS 

INJ NORADR -2 ampoules IN 46 ml NS @6 ml/hr

INJ PAN 40 mg IV/OD

TAB PCM 1gm PO/TID

MONITOR VITALS 4th HRLY

2/1/2023 ( DAY 3)

GM UNIT 6

ICU BED 4

S - 

DECREASED APPETITE

NO FEVER SPIKES 

STOOLS PASSED 

O-

PULSE - 86 bpm 

BP -90/60 mmhg on norad 6ml/hr

RR - 26 CPM

SPO2- 98% AT RA

 

TEMP - AFEBRILE

CVS - S1 , S2 +

RS - BAE + , NVBS

PA - SOFT , NT.

         NO ORGANOMEGALY 

CNS - NAD

INPUT - 

OUTPUT-

A- 

DENGUE SHOCK SYNDROME WITH THROMBOCYTOPENIA WITH AKI ( PRE RENAL -NON OLIGURIC) WITH ACUTE LIVER INJURY 

P-

IVF - 1 NS WITH 1 AMPOULE OF OPTINEURON @ 100 ml/hr

IVF NS , RL ,DNS @ 150 ml /hour 

INJ NORADR -2 ampoules IN 46 ml NS @6 ml/hr

INJ. MONOCEF 1gm IV/BD

TAB PCM 650 mg PO/TID

MONITOR VITALS 4th HRLY

3/1/2023 ( DAY 4)

GM UNIT 6

ICU BED 4

S - 

DECREASED APPETITE

NO FEVER SPIKES 

STOOLS PASSED 

O-

PULSE - 96 bpm 

BP - 80/50 mmhg on norad 4ml/hr

RR - 32 CPM

SPO2- 97 % AT RA

 

TEMP - AFEBRILE

CVS - S1 , S2 +

RS - BAE + , NVBS

PA - SOFT , NT.

         NO ORGANOMEGALY 

CNS - NAD

INPUT - 4850

OUTPUT-4300

HAEMOGRAM:

         Hb – 9.7 gm/dl

         TLC – 6700cells/cu mm

         PLC - 16000

RENAL FUNCTION TESTS :

         Urea : mg/dl

         Creatinine : mg/dl

         Sodium : 140 mEq/L

         Potassium : 6.6 mEq/L

         Chloride : 105mEq/L

A- 

DENGUE SHOCK SYNDROME WITH THROMBOCYTOPENIA WITH AKI ( PRE RENAL -NON OLIGURIC) WITH ACUTE LIVER INJURY 

P-

IVF - 1 NS WITH 1 AMPOULE OF OPTINEURON  @ 100 ml/hr

IVF NS , RL ,DNS @ 150 ml /hour 

INJ NORADR -2 ampoules IN 46 ml NS @4 ml/hr

INJ LASIX 20 mg IV OD ( IF SBP >110 mmhg)

TAB DOXY 100 mg PO/BD

MONITOR VITALS 4th HRLY