CASE -1

Name: A. Greeshma 
Roll no : 148
Introduction:
 40 yr old female came to gen medicine department with chief complaints of fever since 3 days , cold since 4days complaints of cough with sputum , body pains since 3 days , headache since 3days, nausea since 1 day,vomiting since 1 day.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 4 days back. Then she was developed cold and fever which is high grade and intermittent , associated with chills and rigor  relieve on taking medication ,cough since 4 days which is productive and mucoid in colour and scanty amount . Body pains since 3 days  and  headache since 3days . Nausea since 1day and vomiting since 1 day with 3 episodes , non projectile, non bilious , food as content.       She went to RMP and took  unknown medication  but her symptoms were not come down so she came to kims hospital and she was admitted. 
Past illness:
No h/o burning micturition , chest pain ,Short ness of breath ,  abdominal pain , dark coloured stools .
No h/o DM, HTN, , epilepsy ,asthma
H/o Tb  10 yrs back  complete 6 months course taken. 


Personal history:
Married 
Diet: mixed
Appetite: decreased 
Bowel movements: normal
Bladder movements: normal
Sleep: normal
Addictions: alcohol - regular.
                  
Family history:
Not k/c/o DM HTN asthma 
Stroke to patients  mother
Tb to patients father( expired 20 yrs back )
General examination:
pallor 
No  icterus 
No cyanosis
No lymphadenopathy
No clubbing 
No oedema of feet
Temperature: 104 F  
Pulse rate: 108/ min
Respiration rate: 32 per min 
Bp: 110/70 mm Hg
Spo2 97%
GRBS 222mg %
Systemic examination:
CVS
No thrills 
S1S2 present
No murmurs
Respiratory examination:
No dysnopea
No wheezing
Position of trachea is central
Breath sounds are vesicular
Abdominal examination:
Shape of abdomen- scaphoid
No tenderness
No palpable mass
Hernial orifices are normal
No free fluid
No bruits
Liver not palpable
Spleen not palpable
Bowel sounds no
CNS
llevel of consciousness- conscious
Speech normal
Signs of meningeal irritation:
    a) no neck stiffness
    b) no kernigs sign
Cranial nerves normal 
motor system normal
Sensory system normal
Glass gow scale normal 15/15
Reflexes
All are normal
Provisional diagnosis: 
Dengue NS1 POSITIVE
Treatment:
IVF 2 ONS 2 ORL
Inj . NEOMAL 1g iv stat
Tab. DOLO 650 mg TID
Tab. PANTAPRAZOLE 40 mg OD
Plan of care : conservative




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