20 yr old female with NS 1 antigen positive

This is an online e logbook to discuss our patients deidentified health data shared after taking her/guardian's signed informed consent
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs

This E log also reflects my patient centre’s online learning portfolio and valuable inputs on the comment box is welcome.

CASE :

A 20year old female, student, came to casualty with complaint of fever since 5 days and vomitings since 5 days

Patient was apparently asymptomatic 5days back, then complainted of fever which was insidious in onset, continuous type with no diurnal variations and associated with vomiting 2-3 episodes per day, non bilious with food particles as content, non projectile.
Patient also has generalized weakness and complaint of abdominal discomfort in epigastric region and left hypochondrium since 5days.
For which she went to a local hospital and  her fever has got subsided by treatment,
No h/o bleeding gums, malena, petechaie, rash, headache.
She was referred to our hospital in view of low platelet count (28,000/cumm)

Patient is not a k/c/o diabetes, hypertension, asthma, tuberculosis, epilepsy and CAD

Patient has mixed diet with normal appetite and has regular bowel and bladder habits with no known allergies and has no addicitons

Menstrual history:
She attainted menarche at 17yrs of age, with regular cycles for every 28days with 5 days of flow not associated with pain and clots

On examination, patient is conscious, coherent, cooperative.
No pallor, icterus, cyanosis, clubbing, kylonychia, lymphadenopathy and oedema

VITALS :
Temp - 98.4 F
BP - 100/80 mmHg
PR - 89 bpm
RR - 16 cpm
SpO2 - 98 % at RA
GRBS - 147 mg/dL

On systemic examination
CVS - S1, S2 heard, No murmurs
RS - Bilateral air entry present, with normal vesicular breath sounds heard
Per Abdomen - soft, No organomegaly, Bowel sounds heard
CNS - NAD

PROVISIONAL DIAGNOSIS:

Dengue fever ( NS1 positive ) with thrombocytopenia 

Investigations :
Hemogram :
Hemoglobin - 13.6 gm/dl
Total count - 4400 cells/cumm
Neutro - 41
Lympho - 51
Eosino - 1
Mono - 7
Baso - 0
PCV - 39.7
RBC Count - 4.91 millions/cumm
Platelet count - 19000/cumm (d)

Complete urine examination : 
Acidic 
Albumin - trace 
Sugar - nil
Pus cells - 2-3 
Red blood cells - nil
Cast - nil
Crystal- nil

Blood grouping and typing : O positive 

APTT : 33 sec 

PT : 16sec

INR : 1.11

Random blood sugar : 101 mg/dl
 
Renal function test 
Sr. Creatinine - 0.7 mg/dl
Sr. Urea - 14 mg/dl
Sr. Na - 138 mEq/L
Sr. K - 4.3 mEq/L
Sr. Cl - 97 mEq/L (D)

Liver function test :
Total bilirubin - 1 mg/dl
Direct bilirubin - 0.18 mg/dl
AST - 173 IU/L (I)
AST - 70 IU/L (I)
ALP - 219 IU/L (I)
TOTAL PROTEIN - 5.6 gm/dl (D)
Albumin - 3 gm/dl (D)
A/G - 1.19 

Serology - ( HIV, HbsAg, HCV ) - negative 

Chest X ray PA view :


ECG :


Ultrasound abdomen :


2D ECHO :

Fever charting :


Treatment :
Day 0 
- IV Fluids 2 NS , 2 RL, 1 DNS  at 75ml/hr
- INJ. PANTOP 40 mg IV/ OD
- INJ. ZOFER 4 mg IV/ BD
- TAB. DOLO 650 mg PO/ SOS
- INJ. NEOMOL 1gm / IV / SOS ( if temp >101 F )


Day 1 
No fever spikes, no bleeding manifestations ( hematemesis, malena, bleeding gums )

Vitals 
Temp - 98 F
BP - 100/60 mmhg
PR - 80 bpm
RR - 16 cpm
SpO2 - 99% at RA
GRBS - 140 mg/dl
Input - 1900 ml
Output - 1000 ml
CVS - S1 S2 heard 
RS - BAE present, NVBS heard 
Per Abdomen- soft, BS heard 
CNS - NAD
Investigations:
Hb - 12.7
TLC - 5000
RBC - 4.94
PLT - 39000

Treatment given
- IV Fluids 2 NS , 2 RL at 75ml/hr
- INJ. PANTOP 40 MG IV/ OD
- INJ. ZOFER 4MG IV/ BD
- TAB. PCM 650MG PO/ SOS
- Thrombrophobe Ointment for local application 



Day 2 
No fever spikes,
C/o cough

Vitals 
Temp - 98.5 F
BP - 100/70 mmhg
PR - 86 bpm
RR - 14 cpm
SpO2 - 99% at RA
GRBS - 93 mg/dl
CVS - S1 S2 heard 
RS - BAE present, NVBS heard 
Per Abdomen- soft, BS heard 
CNS - NAD

Investigations:

Hb - 11.9
RBC - 4.29
PLT - 39000
TLC - 4000
TB - 1.06
DB- 0.3
AST - 194
ALT - 68
ALP - 190
TP - 5.9
ALB - 2.9

Treatment given

- IV Fluids 2 NS , 2 RL at 75ml/hr
- INJ. PANTOP 40 MG IV/ OD
- INJ. ZOFER 4MG IV/ BD
- TAB. PCM 650MG PO/ SOS
- SYP. ASCORIL-LS PO SOS
- SYP. MUCAINE GEL PO BD
- Thrombrophobe Ointment for local application


Day 3
No fever spikes,
Cough decreased

Vitals 
Temp - 98.5 F
BP - 110/70 mmhg
PR - 86 bpm
RR - 15 cpm
SpO2 - 99% at RA
GRBS - 106 mg/dl
CVS - S1 S2 heard 
RS - BAE present, NVBS heard 
Per Abdomen- soft, BS heard 
CNS - NAD

Investigations:

Hb - 11.6
RBC - 4.17
PLT - 60000
TLC - 3500


Treatment given

- IV Fluids 2 NS , 2 RL at 75ml/hr
- INJ. PANTOP 40 MG IV/ OD
- INJ. ZOFER 4MG IV/ BD
- TAB. PCM 650MG PO/ SOS
- SYP. ASCORIL-LS PO SOS
- SYP. MUCAINE GEL PO BD
- Thrombrophobe Ointment for local application

Day 4
No fever spikes,
No new complaints

Vitals 
Temp - 98.5 F
BP - 120/70 mmhg
PR - 88 bpm
RR - 16 cpm
SpO2 - 99% at RA
GRBS - 106 g/dl
CVS - S1 S2 heard 
RS - BAE present, NVBS heard 
Per Abdomen- soft, BS heard 
CNS - NAD

Investigations:

Hb - 11.4
RBC - 4.11
PLT - 120000
TLC - 4000


Treatment given

- Plenty of oral fluids
- INJ. PANTOP 40 MG IV/ OD
- INJ. ZOFER 4MG IV/ BD
- TAB. PCM 650MG PO/ SOS
- SYP. ASCORIL-LS PO SOS
- SYP. MUCAINE GEL PO BD
- Thrombrophobe Ointment for local application

Course in the hospital :

A 20year old female, student, came to casualty with complaint of fever since 5 days and vomitings since 5 days

Patient was apparently asymptomatic 5days back, then complainted of fever which was insidious in onset, continuous type with no diurnal variations and associated with vomiting 2-3 episodes per day, non bilious with food particles as content, non projectile.
Patient also has generalized weakness and complaint of abdominal discomfort in epigastric region and left hypochondrium since 5days.
For which she went to a local hospital and  her fever has got subsided by treatment,
No h/o bleeding gums, malena, petechaie, rash, headache.
She was referred to our hospital in view of low platelet count (28,000/cumm)

Here we managed the patient conservatively with iv fluids, anti emetic and antipyretics. She complainted of cough for which she was given Syrup ascoril during the stay in hospital.
As the platelet count has improved from 19000 to 1.20 lakh, patient was discharged with medication and adviced for follow up after 1 week

Advice at discharge :

 - Plenty of oral fluids 
 - TAB. ZINCOVIT / PO/OD for 15 days 
 - TAB. DOLO 650mg/PO/SOS



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