55 Year old male farmer with Fever and headache

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55 year old male patient farmer by occupation came with the chief complaints of

1.Fever since 5 days

2.Headache since 5 days

Patient was apparently normal 5 days back then he developed fever,low grade, intermittent,not associated with chills and rigors, relieved on talking medications.

Headache in the frontal region,not associated with any vomitings, blurring of vision and giddiness

No history of any blood in stools and hematuria.

Past history:

Not a K/C/O HTN, DM, Bronchial asthma,CAD

Family History:

No family history of HTN, DM, bronchial asthma, epilepsy

General examination:- 

Patient is conscious,coherent, cooperative,Oriented to time,place and person

No signs of pallor,icterus,cyanosis,lymphadenopathy&pedal edema

Vitals:

Temp:- 98.3 F

BP:Supine:100/70 mm of hg

Standing-90/70 mm of hg(after three minutes)

RR:- 20 cpm

PR:- 68 bpm

Systemic examination:-

CVS- S1, S2 heard,

RS:BAE present

P/A: soft

CNS:HMF intact

Investigations:

LFT:-

TB-0.73

DB-0.26

SGOT-102

SGPT-50

ALP-234

TP-6.4

ALB-3.7

RFT:-

Urea-35

Creat-1.2

Uric acid-6.1

Calcium-9.9

Phosphorus-3.5

Sodium-138

Pottasium-3.7

Chloride-98

RBS-114.

Blood for MP-Negative

BGT:- "O" Positive

USG Abdomen:-

Impression:

1.Mild gallbladder wall edema

2.Grade 1 fatty liver

3.Borderline prostatomegaly

Chest Xray:

Diagnosis:Viral pyrexia with thrombocytopenia (dengue NS1 positive)

Treatment given:

1.IVF 1unit NS ,RL @125 ml/hr

2.INJ. ZOFER 4 mg /IV/SOS

3.Temp monitoring every hrly

4.Bp monitoring every 4th hrly

5.w/ f bleeding manifestations

6.Strict i/o charting