Case history 04

 Case presentation 04

Date of admission: 19-09-2021

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A 17 yr old boy came to OPD with chief complaints of fever , vomiting since 4days and abdominal pain since 1 day.

HISTORY OF PRESENT ILLNESS:

Patient was asymptomatic 4 days back then patient complaints of fever which is insidious in onset, intermittent associated with chills, rigor, body pains and generalised weakness.

Patient complaints of vomiting (2, 3 episodes/day) which is non-bilious, non projectile with food and water as content with abdominal discomfort and pain.

Patient also experience abdominal pain which is squeezing type, non- radiating and confined to epigastric and right hypochondral region which increase on deep breathing.

There is loss of appetite since 4 days.

PAST HISTORY: 

There is no history of hypertension, DM, asthma, epilepsy and Tuberculosis.

FAMILY HISTORY:

There is no history of similar complaints in the family. There is no history of cancer and sudden death.

PERSONAL HISTORY:

Appetite: lost since 4 days

Diet : mixed

Sleep: adequate

Bowel and bladder habits: Normal 

Burning micturition is seen.

PHYSICAL EXAMINATION

A.GENERAL EXAMINATION: patient was conscious, coherent, cooperative and well oriented to time, place and person.

There is no pallor, cyanosis, icterus, and generalised lymphadenopathy.

 VITALS:

 Temperature : 99.F

              Pulse rate : 96bpm

              Respiratory rate : 24 cycles per minute

              BP : 120/80mm Hg In supine position

                       100/60mm Hg in standing position

               SpO2 : 98 %

B.SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

Chest wall is bilaterally symmetrical.

No precordial bulge

No visible pulsation, engorged veins, scars and sinuses

AUSCULTATION: S1 and S2 sounds are heard

RESPIRATORY SYSTEM:

Postion of trachea - central

Bilateral air entry- positive

There is decrease normal vesicular breath sounds 

PER ABDOMEN:

Abdomen is soft and mild tenderness is seen in epigastric and right hypochondral region.

Bowel sounds heard

free fluid is seen.

CENTRAL NERVOUS SYSTEM:

Patient is conscious

Speech - Normal

No signs of meningeal irritation

Motor and sensory system - normal

Reflexes- present

Cranial nerves- intact

PROVISIONAL DIAGNOSIS: 

Viral pyrexia under evaluation.

INVESTIGATIONS:

FINAL DIAGNOSIS: viral pyrexia with thrombocytopenia with serositis ( DENGUE NS1 ANTIGEN POSITIVE).

TREATMENT:

DAY 1

1. Inj PANTOP 40mg/OD

2. Inj zofer 4mg

3. Inj optineuron 1 amp

4. tab PCM 500mg PO/SOS

5. Syrup MUCAINE GEL 15ml P0/SOS

6. Temperature charting

7. I/0 CHARTING

  

DAY 2

AB POSITIVE (SDP) is transfused 

1. Inj PANTOP 40mg/OD

2. Inj zofer 4mg

3. Inj optineuron 1 amp

4. tab PCM 500mg PO/SOS

5. Syrup MUCAINE GEL 15ml P0/SOS

6. Temperature charting

7. I/0 CHARTING

Day 3

1. Inj PANTOP 40mg/OD

2. Inj zofer 4mg

3. Inj optineuron 1 amp

4. tab PCM 500mg PO/SOS

5. Syrup MUCAINE GEL 15ml P0/SOS

6. CREMAFFIN PLUS 15ml

7. Temperature charting

8.I/0 CHARTING

Day 4

1. Inj PANTOP 40mg/OD

2. Inj zofer 4mg

3. Inj optineuron 1 amp

4. tab PCM 500mg PO/SOS

5. Syrup MUCAINE GEL 15ml P0/SOS

6. Temperature charting

7. I/0 CHARTING

Questions:

1. Why subsequent ( secondary infection) with different serotype is dangerous?

2. Why RBC is resistant to destruction in dengue fever?

3. Recently, i found a patient where she has been IgM positive for one month where IgG and NS 1 antigen are negative. Is patient is at risk of developing any other serious complication?

4. Can we ruled out dengue if the patient has adequate platelet count though IgM positive for dengue for a month?

5. Is there any possibility of vertical transmission in dengue?