A 25 year old male with dengue fever

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case i have seen:

A 25 year old male came with 

C/ o fever since 3days
C/o loose stools since 2days
C/o vomitings since morning
Patient was apparently asymptomatic 3days back then he developed fever which was insidious in onset ,gradually progressive associated with chills and rigors ,fever subsided on medication
C/o loose stools ,watery in consistency ,4-5 episodes in a day @yesterday
Today 3episodes in a day
C/o vomitings (non projectile ,non bilious in consistency)
C/o burning mictuaration since 2days
No c/o dyspnea ,cold ,cough,palpitations,headache,pedal edema,sob,chest pain ,petechiae, purpura,rash
Not a k/c/o of Dm,htn,epilepsy,tb ,asthma
Personal h/o :
Pt has normal mixed diet
No loss of apetite
Bowel and bladder movements normal
No addictions
O/e : pt is c/c/c
No pallor,icterus,clubbing,cyanosis,edema,
Lymphadenopathy
Vitals:
Patient was afebrile
PR - 67bpm
BP-100/80 mmhg
RR-19cpm
GRBS-148 mg/dl
Cvs -s1s2 heard ,no murmers
Rs-b/l air entry present
P/a-soft ,non tender
No organomegaly
Bowel sounds present
CNS-NFD
investigations-
CBP-
HB-13.5
TLC-4.21
PLT-32000
RFT:

ECG:

Chest xray:

Usg abdomen:

BGT- O POSITIVE

Stool for c/s : normal flora grown 

Treatment :
1.IVF NS @125ml/hr
RL
DNS
2.inj pantop 40mg/iv/od
3.inj zofer 4mg/iv/tid
4.ors sachets 2 in 1 litre water ,200ml after each episode
5.tab sporolac ds/bd
6.oral fluids 4 litre/day
7.bp/pr/temp hourly 

Day 2:

O/e : pt is c/c/c
No pallor,icterus,clubbing,cyanosis,edema,
Lymphadenopathy
Vitals:
Patient was afebrile
PR - 72bpm
BP-110/80 mmhg 
RR-19cpm
GRBS-148 mg/dl
Cvs -s1s2 heard ,no murmers
Rs-b/l air entry present 
P/a-soft ,non tender 
No organomegaly 
Bowel sounds present 
CNS-NFD
investigations-
CBP- 
HB-14.6
TLC-4.52
PLT-21000

Treatment :
1.IVF NS @125ml/hr 
RL 
DNS
2.inj pantop 40mg/iv/od
3.inj zofer 4mg/iv/tid
4.ors sachets 2 in 1 litre water ,200ml after each episode
5.tab sporolac ds/bd
6.oral fluids 4 litre/day
7.bp/pr/temp hourly 

Day 3:

O/e : pt is c/c/c
No pallor,icterus,clubbing,cyanosis,edema,
Lymphadenopathy
Vitals:
Patient was afebrile
PR - 64bpm
BP-100/80 mmhg 
RR-19cpm
GRBS-148 mg/dl
Cvs -s1s2 heard ,no murmers
Rs-b/l air entry present 
P/a-soft ,non tender 
No organomegaly 
Bowel sounds present 
CNS-NFD

Investigations:

Hb-14.5 

Tlc:6100

Plt:11,000

Treatment:

1.IVF NS @125ml/hr 
          RL 
          DNS
2.inj pantop 40mg/iv/od
3.inj zofer 4mg/iv/tid
4.ors sachets 2 in 1 litre water ,200ml after each episode
5.tab sporolac ds/bd
6.oral fluids 4 litre/day
7.bp/pr/temp hourly 

8.SDP transfusion done at 10pm

Day 4:

O/e : pt is c/c/c
No pallor,icterus,clubbing,cyanosis,edema,
Lymphadenopathy
Vitals:
Patient was afebrile
PR - 67bpm
BP-110/80 mmhg 
RR-19cpm
GRBS-148 mg/dl
Cvs -s1s2 heard ,no murmers
Rs-b/l air entry present 
P/a-soft ,non tender 
No organomegaly 
Bowel sounds present 
CNS-NFD

Investigations:

Hb-13.7

Tlc:6,000

Plt:20,000

Treatment:

1.IVF NS @125ml/hr 
          RL 
          DNS
2.inj pantop 40mg/iv/od
3.inj zofer 4mg/iv/tid
4.ors sachets 2 in 1 litre water ,200ml after each episode
5.tab sporolac ds/bd
6.oral fluids 4 litre/day
7.bp/pr/temp hourly 

Day 5:

O/e : pt is c/c/c
No pallor,icterus,clubbing,cyanosis,edema,
Lymphadenopathy
Vitals:
Patient was afebrile
PR - 54bpm
BP-110/70 mmhg 
RR-19cpm
GRBS-148 mg/dl
Cvs -s1s2 heard ,no murmers
Rs-b/l air entry present 
P/a-soft ,non tender 
No organomegaly 
Bowel sounds present 
CNS-NFD

Investigations:

Hb-12.2

Tlc:5,100

Plt:25,000

Treatment:

1.IVF NS @125ml/hr 
          RL 
          DNS
2.inj pantop 40mg/iv/od
3.inj zofer 4mg/iv/tid
4.ors sachets 2 in 1 litre water ,200ml after each episode
5.tab sporolac ds/bd
6.oral fluids 4 litre/day
7.bp/pr/temp hourly