24 yr old male 8/11/21

Amc bed 1

24 yr old male pt presented to op with 
c/o fever since 4 days 
Generalised weakness since 3 days 

Pt was appently asymptomatic 4 days back , then developed fever a/w chills and rigors , 
not a/w nausea , vomiting 
C/o generalised weakness since 3 days 
H/o similar complaints in the past ( 1 and half yr ago) was told he had low platelet count 
Not a k/c/o DM /htn / tb / asthma / epilepsy 

O/E : 
PR 99 bpm

BP 110/80 mmHg 

RR 18 cpm

Temp 98 .5 F 
Grbs 115 mg/dl 
Spo2 99% room air 

CVS : 
S1 S2 heard , no murmurs 

RS : 
VBS + 
BAE + 


P/A : 
Shape : scaphoid 
Soft , non tender 
Bowel sounds + 

CNS : NAD ,HMF INTACT 

Investigations : 
APTT 32 sec
Pt 16
INR 1.11
Bgt : o positive 
Blood urea : 20 
CUE : 
Alb +
Sugar +
Pus cells 3-4 
Uric acid serum 3.3 
S .electrolytes : 
Na 137 , K 4.4 , Cl 98 
S creat : 0 .8 

LFT : 
TB 2.08 
DB 0.86 
Ast 98 , ALT 79 
Alp 281 
TP 6.4 
Alb 4.3 
A/G ratio 2.06 

Hemogram : 
HB : 16.3 
TC : 5000
N : 76 
L : 18 
PCV : 45.6 
PLT : 50,000 


Provisional diagnosis : 
Dengue with NS1 Antigen positive 

Treatment : 
IVF NS, RL 100 ml/hr 
INJ pantop 40 mg/IV / stat 
INJ neomol 100 mg /iv/ if temp > 101 F 
Tab PCM 500 mg /po/od 
Watch for bleeding manifestations 
Check postural htn 
INJ optineuron 1 AMP in 100 ml NS /iv /od

9/11/21

HEMOGRAM:

HB: 17.3
TC:7200
PLT:50,000

SHIFTED TO WARD.

10/11/21

SOAP NOTES DAY 2
WARD CASE

S:
no fever spikes
No fresh complaints.

O:
Pt is c/c/c
Temp: 97.6F
Bp:110/80mmhg
PR: 60bpm
RR: 18cpm
SPO2: 98%
CVS: S1S2+
P/A: soft, non tender
RS: BAE+
CNS: NAD

HEMOGRAM:
HB:17.2
TC:10,600
PLT: 40,000
A:
DENGUE NS1 ANTIGEN POSITIVE WITH 
THROMBOCYTOPENIA.

P:
IVF NS, RL 100 ml/hr 
INJ pantop 40 mg/IV / stat 
INJ neomol 100 mg /iv/ if temp > 101 F 
Tab PCM 500 mg /po/od 
Watch for bleeding manifestations 
Check postural htn 
INJ optineuron 1 AMP in 100 ml NS /iv /od
PCV- 12th hrly.

11/11/21

WARD
SOAP NOTES DAY 3

S:
no fever spikes
Complaints of Malena since 2days.


O:
Pt is c/c/c
Temp: 98.5F
Bp:110/70mmhg
PR: 64bpm
RR: 18cpm
SPO2: 98%
CVS: S1S2+
P/A: soft, non tender
RS: BAE+
CNS: NAD

HEMOGRAM:
HB:16.0
TC:12,900
PLT: 50,000

A:
DENGUE NS1 ANTIGEN POSITIVE WITH 
THROMBOCYTOPENIA.

P:
IVF NS, RL 100 ml/hr 
INJ pantop 40 mg/IV / stat 
INJ neomol 100 mg /iv/ if temp > 101 F 
Tab PCM 500 mg /po/od 
Watch for bleeding manifestations 
Check postural htn 
INJ optineuron 1 AMP in 100 ml NS /iv /od
PCV- 12th hrly.

12/11/21
24 yr old male.

WARD
SOAP NOTES DAY 4

S:
no fever spikes
Complaints of Malena since 3days.


O:
Pt is c/c/c
Temp: 98.5F
Bp:120/70mmhg
PR: 82bpm
RR: 18cpm
SPO2: 98%
CVS: S1S2+
P/A: soft, non tender
RS: BAE+
CNS: NAD

HEMOGRAM:
HB:15.7
TC:12,000
PLT: 80,000

A:
DENGUE NS1 ANTIGEN POSITIVE WITH 
THROMBOCYTOPENIA.

P:
IVF NS, RL 100 ml/hr 
INJ pantop 40 mg/IV / stat 
INJ neomol 100 mg /iv/ if temp > 101 F 
Tab PCM 500 mg /po/od 
Watch for bleeding manifestations 
Check postural htn 
INJ optineuron 1 AMP in 100 ml NS /iv /od
PCV- 12th hrly.

DISCHARGED

















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