Case No: 3

PATIENT DEMOGRAPHIC DETAILS:

Name : Devayani Dept : General Medicine-II

M.R.D no : 146623 Age Sex : 56yrs : Female

D.O.A : 1.1.14 D.O.D :

REASON FOR ADMISSION

Fever-low grae (without rigor) Non-radiating back-pain Recent history of dengue fever last week

PAST MEDICAL & MEDICATION HISTORY H/O DM & HTN & DVT

ON EXAMINATION
Conscious, oriented No raised JUP/ Edema P/A : Soft, non tender No Organomegaly

PROVISIONAL DIAGNOSIS: Dengue fever

VITAL SIGNS
VITALS B.P mm Hg PULSE (per min) R.RATE (per min) TEMP (0F) 1 130/80 2 150/90 3 140/80 4 140/80

78

78

88

78

22

20

24

22

98.6

98.6

98.6

98.6

LAB INVESTIGATION ORDERS

Patient value Test 1/1/14 3/1/14 4/1/14 Normal value

BIOCHEMISTRY Serum creatinine SGOT SGPT ALP 0.8 mg/dL 89 U/L 63 U/L 143 U/L 153 U/L 0.7mg/dL 0.5-1.4 mg/dL 5-35 U/L 7-56 U/L 100-250 U/L

BLOOD ROUTINE EXAMINATION Hb Total RBC count 13gm% 4.44 million/cu 2.9x1000 cells/mm
3

12.9gm%

11-18 gm% 3.8-5.6 million/cu 4000-11000 cells/mm3

WBC count RDW PCV MCHC

14.2% 36% 36%

11-18% 35-49% 32-38%

MCV MCH Platelet count 238x1000 c/cu 160x1000 c/cu

84fl 30pg 135x1000 c/cu

76-96fl 26-32pg 150-450 x1000 c/cu

Polymorph Lymphocyte Eosinophil Monocyte Basophil

63% 35% 2% 0% 0% URINE ROUTINE EXAMINATION

45-75% 20-45% 0-6% 0-8% 0-2%

Appearance Albumin Sugar Pus cells Epithelial cells RBC Crystals Casts

Slightly turbid Nil Nil 1-2/hpf 2-3/hpf Nil Nil Nil SERUM ELECTROLYTES

Clear

0-1/hpf 0-2/hpf Nil Nil

Serum Calcium Serum Phosphate

9.2 mg/dL 2 mg/dL OTHER

8.4-10.2 mg/dL 2.5-4.8mg/dL

Dengue NS1Ag

Positive

MEDICATIONS

DRUG

GENERIC

T. Lostat 50mg 1-0-0

Lostat + Hydrochlorthiazide

+ stp stop

T. Arthropan

Choline Salicylate

IVF NS 1pint iv q8h

T. Glyciphage

Metformin

T. Lanol ER 1-0-1

Paracetamol

T. Rabemac DSR 1-0-0

Rabeprazole

IVF DNS 1pint q8h