General medicine short case
30/07/22
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A 13 year old school going boy presented to opd with cheif complaints of
- high grade fever since 4 days
- vomitings since 4 days
- giddiness since 4 days
- loose stools since 1 day
HISTORY OF PRESENT ILLNESS -
Patient was apparently asymptomatic 4 days back then he developed fever associated with chills.
Complaints of vomiting since 4 days- 2-3 episodes/day with food particles as content
Loose stools- 5 episodes in the past one day
No history of burning micturion, rashes, bleeding gums, hematuria
VITALS
Temp- 98.8 F
PR- 90 bpm
BP- 100/60 mmHg
RR- 18 cpm
Spo2- 98% at RA
GRBS- 118mg%
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative well oriented to time and place and have no signs of -
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy or Edema.
CVS: S1 S2 heard, no murmurs/thrill sp
Position of trachea central
Palpation of Abdomen: Soft, non tender. Liver and Spleen not palpable.
Bowel sounds heard
INVESTIGATIONS
Outside Reports:-
Platelets- 102000 lakhs/cu.mm
Hb- 15.6 mg/dl
TLC- 2,300
PLT- 45,000
BGT- AB POSITIVE
BLOOD MALARIAL PARASITE- NEGATIVE
RBS- 110 mg/dl
DENGUE NS1 +
Serum Urea- 13
Serum Creatinine- 0.6
Na- 135
K- 3.0
Cl- 96
Total Bilirubin- 0.40
Direct Bilirubin- 0.18
Aspartate aminoTransferase- 10
Alanine aminotransferase- 9
Alkaline phosphatase- 110
USG ABDOMEN
ECG
PROVISIONAL DIAGNOSIS
NS 1 + DENGUE
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