50 year old male farmer by occupation.

Chief complaints
Fever ( 10 days )
Lethargy ( 4 days )
Blood in saliva ( 3 days )
SOB ( 2 days )
Patient was apparently alright 10 days ago back he had fever low grade , intermittent , relieved on taking medication . Not associated with chills and rigor and doing his routine works , from 4 days as patient was lethargic brought to local hospital found out to be Dengue NS 1 reactive and platelet count was 
44000 ( 1/3/22 ) 
22000 ( 2/3/22 ) one SDP transfusion
33000 ( 3/3/22 )
From 3 days patient notices blood in saliva and while during coughing associated with Black coloured stools from 2 days patient is having Grade 2 to Grade 4 ( NYHA )
N/K/C/O DM , HTN , TB , ASTHMA , EPILEPSY

PERSONAL HISTORY :

Diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movements- regular
Occasional alcohol intake +
No known allergies
FAMILY HISTORY: 
Not significant

GENERAL EXAMINATION:

No Pallor 
No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema
No neck stiffness
Kernig and Brudzinski sign negative
VITALS AT ADMISSION :
Temp.- Afebrile
PR- 55 bpm
RR- 24 cpm
BP- 130/70 mmHg
SpO2- 92% at RA , 98% on 4 lit O2
GRBS- 137 mg/dl
SYSTEMIC EXAMINATION:
CVS: S1S2 heard, no murmurs
RS: R/s- B/LAE+,inspiratory crept’s present in (RT>LF) infraaxillry,infrascapular areas
P/A: Soft, Non-tender
CNS: NAD


PROV DIAGNOSIS : 

Dengue NS 1 reactive , IgM positive with Thrombocytopenia, with Mild ARDS

TREATMENT : 
1. IVF NS , RL @ 75 ml/hr
2. Daily postural BP monitoring
3. W/F Bleeding manifestation
4. I/O strict monitoring

S.O.A.P notes

5/3/22
S : 
Fever and SOB
O : 
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA

VITALS - 
TEMPERATURE - 98.1
PULSE RATE - 60 bpm
BLOOD PRESSURE - 110/70 MM OF HG 
RESPIRATORY RATE - 
SPO2 - 100 % AT 4 lit O2
I - 1900 ml
O - 500 ml
HB - 10.8 4/3/22
        10.1 5/3/22
Plt - 17000 4/3/22
       18000 5/3/22

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : 
 B/LAE+,inspiratory crept’s present in (RT>LF) infraaxillry,infrascapular areas
CENTRAL NERVOUS SYSTEM : NAD

A : 
Severe ARDS with Dengue NS 1 reactive with Thrombocytopenia . ( H/O 1 SDP and 1 FFP transfusion )

P : 
1. IVF NS , RL @ 50 ml/hr
2. W/F Bleeding manifestation
3. Strict I/O charting
4. BP monitoring

6/3/22
S : 
Fever ( subsided ) and SOB
O : 
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA
VITALS - 
TEMPERATURE - 98.1
PULSE RATE - 60 bpm
BLOOD PRESSURE - 110/70 MM HG 
RESPIRATORY RATE - 35 cpm
SPO2 - 100 % AT 4 lit O2
I - 2000 ml
O - 1050 ml
HB - 10.8 4/3/22
        10.1 5/3/22
        9.8 6/3/22
Plt - 17000 4/3/22
       18000 5/3/22
       52000 6/3/22
PaO2 / FiO2 = 289 

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : 
 B/LAE+,inspiratory crept’s present in (RT>LF) infraaxillry,infrascapular areas
CENTRAL NERVOUS SYSTEM : NAD
A : 
Dengue NS 1 reactive , IgM positive with Thrombocytopenia, with Mild ARDS . 
P : 
1. IVF NS , RL @ 50 ml/hr
2. W/F Bleeding manifestation
3. Strict I/O charting
4. BP monitoring


S.O.A.P notes

7/3/22
S : 
Fever ( subsided ) and SOB ( subsided )
O : 
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA
VITALS - 
TEMPERATURE - 98.2
PULSE RATE - 70 bpm
BLOOD PRESSURE - 130/90 MM HG 
RESPIRATORY RATE - 24 cpm
SPO2 - 98 % RA

HB - 10.8 4/3/22
        10.1 5/3/22
        9.8 6/3/22
        10.1 7/3/22        
Pt - 17000 4/3/22
       18000 5/3/22
       52000 6/3/22
       50000 7/3/22


      
SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : 
 B/LAE+,inspiratory crept’s present in (RT>LF) infraaxillry,infrascapular areas
CENTRAL NERVOUS SYSTEM : NAD
A : 
Dengue NS 1 reactive , IgM positive with Thrombocytopenia, with Mild ARDS . 
P : 
1. IVF NS , RL @ 50 ml/hr
2. W/F Bleeding manifestation
3. Strict I/O charting
4. BP monitoring
5. CPAP 4th hrly

8/3/22
S : 
Fever ( subsided ) and SOB ( subsided )
O : 
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA
VITALS - 
TEMPERATURE - 98.3
PULSE RATE - 64 bpm
BLOOD PRESSURE - 130/70 MM HG 
RESPIRATORY RATE - 20 cpm
SPO2 - 98 % RA

HB - 10.8 4/3/22
        10.1 5/3/22
        9.8 6/3/22
        10.1 7/3/22
        10.5 8/3/22           
Pt - 17000 4/3/22
       18000 5/3/22
       52000 6/3/22
       50000 7/3/22
       70000 8/3/22

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : 
 B/LAE+,inspiratory crept’s present in (RT>LF) infraaxillry,infrascapular areas
CENTRAL NERVOUS SYSTEM : NAD
A : 
Dengue NS 1 reactive , IgM positive with Thrombocytopenia, with Mild ARDS . 
P : 
1. IVF NS , RL @ 50 ml/hr
2. W/F Bleeding manifestation
3. Strict I/O charting
4. BP monitoring
5. CPAP 4th hrly


S.O.A.P notes
9/3/22
S : 
Fever ( subsided ) and SOB ( subsided )
O : 
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA
VITALS - 
TEMPERATURE - 98.2
PULSE RATE - 78 bpm
BLOOD PRESSURE - 130/80 MM HG 
RESPIRATORY RATE - 23 cpm
SPO2 - 98 % RA

HB - 10.8 4/3/22
        10.1 5/3/22
        9.8 6/3/22
        10.1 7/3/22
        10.5 8/3/22
        10.2 9/3/22            
Pt - 17000 4/3/22
       18000 5/3/22
       52000 6/3/22
       50000 7/3/22
       70000 8/3/22
       81000 9/3/22

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : 
 B/LAE+,inspiratory crept’s present in (RT>LF) infraaxillry,infrascapular areas
CENTRAL NERVOUS SYSTEM : NAD
A : 
Dengue NS 1 reactive , IgM positive with Thrombocytopenia, with Mild ARDS . 
P : 
1. IVF NS , RL @ 50 ml/hr
2. W/F Bleeding manifestation
3. Strict I/O charting
4. BP monitoring
5. CPAP 4th hrly


S.O.A.P notes

10/3/22
S : 
Fever ( subsided ) and SOB ( subsided )
O : 
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA
VITALS - 
TEMPERATURE - 97.4
PULSE RATE - 78 bpm
BLOOD PRESSURE - 120/70 MM HG 
RESPIRATORY RATE - 19 cpm
SPO2 - 98 % 

HB - 10.8 4/3/22
        10.1 5/3/22
        9.8 6/3/22
        10.1 7/3/22
        10.5 8/3/22
        10.2 9/3/22
        10.9 10/3/22           
Pt - 17000 4/3/22
       18000 5/3/22
       52000 6/3/22
       50000 7/3/22
       70000 8/3/22
       81000 9/3/22
       1.25 10/3/22


SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : 
 B/LAE+,inspiratory crept’s present in (RT>LF) infraaxillry,infrascapular areas
CENTRAL NERVOUS SYSTEM : NAD
A : 
Dengue NS 1 reactive , IgM positive with Thrombocytopenia, with Mild ARDS . 
P : 
1. IVF NS , RL @ 50 ml/hr
2. W/F Bleeding manifestation
3. Strict I/O charting
4. BP monitoring
5. CPAP 4th hrly

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