Case of a 27 year old female with Dengue

-
Summer of 2021 

25 year old female Labourer resident of Aitipamula, came to opd with CC of 
• fever since 5 days
 •headache since 6 days 
•loss of appetite since 6 days

HISTORY OF PRESENTING ILLNESS :

• Fever: high grade,  intermittent, associated with chills & rigor - 5 days
• headache : frontal and temporal 
• generalized weakness since 6 days associated with giddiness, sweating, headache and discomfort. 

N/H/O -  cold, cough, SOB, chest pain, palpitations, malena, hematuria, joint pains, pain abdomen, vomiting, loose stools

HISTORY OF PAST ILLNESS: 
No k/c/o HTN, DM-2, TB, Epilepsy, CVA, Asthma 

PERSONAL HISTORY:
• Married life- 7 years
• Kids - 2 
- M, 5 years- NVD - Anemia 
- M, 3 years- NVD - Anemia
- Appetite : Lost

FAMILY HISTORY:
 Mother & Father - HTN, DM2

GENERAL EXAMINATION :

Pt. Is C/C/C

Pallor - Present
Icterus -
Clubbing - 
Koilonychia -
Lymphadenopathy -
Edema 

Dehydration: Mild

VITALS:

BP: 100/60 mmHg - supine, 60/40 mmHg - Standing

PR: 60 bpm

RR:  12 cpm

Temperature: Febrile : 100.3 F 

GRBS: 

SpO2: 99% on RA


SYSTEMIC EXAMINATION

CVS:

S1, S2 heard

No thrills

No murmurs


Resp S:

Trachea centrally located

No dyspnea

No wheeze

Vesicular breath sounds

No Adventitious breath sounds


ABDOMEN:

Shape: Scaphoid

No tenderness

No palpy mass

No bruits

No free fluid


CNS:

Conscious

Coherent

Cooperative

Normal speech

No signs of meningeal irritation


CEREBRAL SIGNS:

None


PROVISIONAL DIAGNOSIS:

Dengue 

INVESTIGATIONS ORDERED: 

Haemogram, CUE, RFT, LFT, Dengue serology, ECG, CXR. BGT. PT, INR, APTT, Serology


TREATMENT HISTORY: 

Day 0 : 

1. IVF RL, NS. DNS : @150 ml/hr 

2. Inj. PANTOP 40mg IV/ OD 

3. Inj. ZOFER 4mg IV/stat 

4. BP : monitoring hourly 

5. GRBS : 2nd Hourly 

6. Temp : 4th Hourly

7. I/O : CHARTING

8. Temp : CHARTING 


Day 1 : 

1. IVF RL, NS. DNS : @150 ml/hr 

2. Inj. PANTOP 40mg IV/ OD 

3. Inj. ZOFER 4mg IV/

4. Inj. NEOMOL 1gm IV/ (If temp ≥ 101 F )

5. Inj. OPTINEURON 1AMP / 1000m/ NS IV/OD 

7. BP MONITORING : 4th Hourly

8. Check for POSTURAL HYPOTENSION

9. GRBS : 2nd Hourly 

10. Temp : CHARTING 4th Hourly

11. I/O : CHARTING 

12. Inj. FALCIGO/20mg/IV/stat


Day 2:

1.IVF RL, NS. DNS : @150 ml/hr

2. Inj. FALCIGO/20mg/IV/stat

3. Inj. PANTOP 40mg IV/ OD 

4. Inj. ZOFER 4mg IV/

5. Inj. NEOMOL 1gm IV/ (If temp ≥ 101 F )

6. Inj. OPTINEURON 1AMP / 1000m/ NS IV/OD 


Day 3:

1.IVF RL, NS. DNS : @150 ml/hr

2. Inj. FALCIGO/20mg/IV/stat

3. Inj. PANTOP 40mg IV/ OD 

4. Inj. ZOFER 4mg IV/

5. Inj. NEOMOL 1gm IV/ (If temp ≥ 101 F )

6. Inj. OPTINEURON 1AMP / 1000m/ NS IV/OD 

7. Tab pcm 500mg x po x QID 

8. BP charting 4th hrly 


Day 4:

1. IVF RL, NS. DNS : @150 ml/hr

2. Inj. PANTOP 40mg IV/ OD 

3. Inj. ZOFER 4mg IV/80c

4. Inj. NEOMOL 1gm IV/ (If temp ≥ 101 F )

5. Tab pcm 500mg x po x TID 

6. BP/PR charting 12th hrly 

7. Temperature charting 4th hrly 

8. GRBS 12th hrly 

9. Tab DOXYCYCLINE 100 mg/po/BD 

10. Inj CEFTRIAXONE 1gm/IU/BD

11. Inj NEOMOL 50ml/IU/4th hrly 


Day 5: 

1. IVF RL, NS. DNS : @150 ml/hr 

2. Tab DOXYCYCLINE 100 mg/po/BD 

3. Inj CEFTRIAXONE 2gm/IU/BD

4. Inj. PANTOP 40mg IV/ OD 

5. Inj. ZOFER 4mg IV/80c

6. Inj. NEOMOL 1gm IV/ (If temp ≥ 101 F ) 

7. Temp charting 2nd hrly

8. GRBS 12th hourly 


INVESTIGATIONS: 
























































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