50 Year old male came to Casuality with Chief complaints of Fever and Chills Since 1 week and Associated with Frontal Headache. No History of Vomiting,Headache,Loose Stools or Abdominal Pain
Past History
Not A K/C/O DM,HTN,Asthma,Epilepsy.
No Allergies
No Past Surgical History
Personal History
Diet -Mixed
Appeteite- Decreased
Bowel And Bladder Movements Regular
Addictions Absent
Family History
No Significant Family History.
Provisional Diagnosis :
Viral Pyrexia
Vitals
Bp 100/60 mmHg
Pulse 75BPM
RR 14cpm
GRBS 437 mg/dl
Pt Is C/C/C well oriented with Time,Place and Person
Pallor Absent
Icterus Absent
Clubbing Absent
Koilonychia Absent
Lymphadenopathy Absent
Edema Absent
Systemic Examination
CVS
S1 S2 Heard
RS
BAE Present
P/A
Soft ,Non Tender.
Provisional Diagnosis
Viral Pyrexia
Investigation
Chest X Ray :
Urine Sugars - Present
Treatment
Tab PCM
Inj Neomol
Inj Zofer 4mg IV SOS
Inj Piptaz 4mg IV BD
Tab Doxy 100mg PO BD
SOAP NOTES DAY 1
Viral Pyrexia Secondary to Dengue
Thrombocytopenia
Vitals
Bp 120/80
PR 75
GRBS 228mg/dl
Treatment :
Tab PCM
Inj Neomol
Inj Zofer 4mg IV SOS
Inj Piptaz 4mg IV BD
Tab Doxy 100mg PO BD
Soap Notes Day 2
Viral Pyrexia Secondary to Dengue
Thrombocytopenia
Bp 110/80
PR 80
GRBS 190 -8Aam
Treatment
Inj Piptaz 4mg IV BD
Tab Doxy 100mg PO BD
Tab PCM
Inj Neomol
Inj Zofer 4mg IV SOS
Tab Pan 40mg PO OD
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