60 y M fever, vomitings and Drowsiness

60y M fever vomiting and drowsiness

October 26, 2023

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Chief complaints:

Fever since 1 day 

Cough since 1 day 

Vomiting since today morning 

HOPI 

pt was apparently asymptomatic then he developed fever which is of high grade intermittent a/w chills and rigor, vomitings

(non projectile non bilious watery filled with food particles) 

No c/o pain abdomen cold loose stools burning Micturition

Past history : 

N/k/c/o HTN , DM , thyroid epilepsy asthma CAD CVD

H/o pneumonia? 3 months back 

General examination 

Pt is conscious coherent cooperative 

No pallor icterus cyanosis clubbing edema lymadenopathy 

VITALS 

BP: 130/80

PR: 86/min

RR: 18/min

Temp: 99F

Spo2 : 99%

GRBS : 98mg%

Systemic examination :

Cvs : s1s2 heard no murmurs 

PA : soft and non tender, no organomegaly 

CNS : No focal neurological deficit

RS : BAE+ b/l crepts present in Rt IAA

Investigations: 

 

      

  PROVISIONAL DIAGNOSIS: 

    Viral pyrexia with thrombocytopenia ( dengue igM positive) 

TREATMENT: 

IV fluids NS or RL @ 100 ml /hr

Inj NEOMOL 1gm I/SOS (if temp > 101F)

Inj ZOFER 4 mg IV/SOS

Tab PCM 650 mg PO/QID

(8am ,2Pm, 8pm, 2 Am )

Monitor vitals 4 hrly