a case of 39 yr old male suffering with fever and chills

is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

 Our patient here is a 39 yr old male, farmer by occupation and resident of nalgonda , had come wt fever, chills, body pains and headache since the past 4 days.
 Pt was a previously known case of dengue.
HOPI: 
Pt was apparently asymptomatic 4 days ago then developed fever with chills which was relieved on medication which he took from the local hospital and had undergone investigations for which he was found to be positive for dengue
He also had a low platelet count of 14,000 so was referred to our hospital
H/O Past illness
Not a known case of hypertension, DM,heart disease,tb, epilepsy, thyroid disorder.

CVS: S1 , S2+
Resp:BAE+
P/A: soft , nontender

Investigation
Ultrasound
Impression:
Gallbladder wall edema
Moderate ascites
B/L Minimal pleural effusion
F/S/O serositis

Soap notes

13/08/22
Pt c/c/c
Temp: 97.8
Bp: 130/80 mmHg
PR: 78bpm
RR:  18/ min
CVS: S1 S2+
CNS: NAD
Lungs: BAE+
 
14/08/22

Pt c/c/c
Temp: 97.2
Bp: 120/80 MMHG
PR: 78bpm
RR: 16/ min
CVS: S1 S2+
CNS: NAD
Lungs: BAE+
 
15/08/22

Pt c/c/c
Temp: afebrile 
Bp: 110/70 mmHg
PR: 70bpm
RR: 18/ min
CVS: S1 S2+
CNS: NAD
Lungs: BAE+

16/08/22
Temp: afebrile 
Bp: 110/70 mmHg
PR: 74bpm
RR: 16/ min
CVS: S1 S2+
CNS: NAD
Lungs: BAE+

 Treatment 
IV fluids 2NS 2RL 
Inj. Pan 40 mg/IV/OD
Inj. ZOFER 4 MG/IV/SOS
INJ. NEOMOL 1GM/IV/SOS
TAB. DOLO 650 MG PO/ SOS
TAB METFORMIN  500 MG PO/OD

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