Case -5

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Date of admission : 8/12/21

A 38 old male patient presented to OPD with the chief complaints of

-fever

-generalized body pains

-cough

-Vomtings  since 4 days

HISTORY OF PRESENT ILLNESS -

The patient was apparently asymptomatic since 5 days then he developed high grade intermittent fever,chills along with generalized body pains, productive cough.

Patient also complaints orthopnea with SOB

Loose stools & black stools along with burning micturition for 2 days

Vomtings 3 episodes per day

PAST HISTORY :-

-Patient was known case of diabetes mellitus and hypertension since 22 years. (got to know when he felt giddiness and went for checkup).

 - Patient underwent hydrocele surgery 4 years back (which was been absconded for 10 years before he underwent the surgery).

 - No history of epilepsy, asthma, TB.

PERSONAL HISTORY :-

Appetite - fullness of stomach with small amount of food.

 Diet - normal. 

Bowel and bladder - normal. 

Habits - occasionally consumes alcohol. no smoking.

 Martial status - married (3 children).

Sleep : orthopnea

FAMILY HISTORY :-

Patient's brother has expired due to similar illness.   

ALLERGY HISTORY :-

Patient does not complain of any drug or food allergies. 

Patient does not have any pollen allergy. 

GENRAL EXAMINATION :-

The patient is concious, coherent and cooperative.

On examination, patient's mood appears to be well and is well built.

 There is no lymphadenopathy present.

 There is no presence of clubbing.

 There is no pallor. 

 There is no icterus.

 There is no cyanosis.

 There is  oedema of feet.

 Patient is not dehydrated

VITALS:

Temperature- 99

Pulse rate- 98 b

Respiratory rate - 22cycles/m

BP- 120/80

Spo2- 98

BLEEDING MANIFESTATIONS:

INVESTIGATIONS:

B+VE blood group

PROVISIONAL DIAGNOSIS: 

Dengue fever

TREATMENT :

The patient was given 2 units of SDP on 9th and 10th.

Plenty of oral fluids.

Dolo 650mg

PANTOP 40 mg OD ×5days

Tab. NEUROBION FORTE OD×15days.