DEPARTMENT OF MEDICINE II

ALL INDIA INSTITUTE OF MEDICAL SCIENCES NEW DELHI-110029

--------------------------------------------------------DISCHARGE SUMMARY
**********************
PATIENT NAME:FAZAR ALI
UHID NO :1023032720
AGE : 40 YRS
SEX:MALE
WARD :C7
BED NO :21
D.O.A:18/10/2016
D.O.D :23/09/2016
--------------------------------------------------------------------DIAGNOSIS:
DENGUE FEVER-RESOLVED
History and physical findings at examination:
40 yrs old male presented with history of fever for 7 days, back
stools for 5 days, vomiting for 4 days, abdominal pain and oral bleed for 3
days . Fever is sudden in onset, high grade with chills, and myalgias. No
history of of cough, expectoration ,burning micturition, altered sensorium.
O/E patient was alert, oriented. Afebrile. vitals were PR-82/min, B.P-110/74
mm of Hg, RR-20/min. Skin-Diffuse Blanching erythema present.
RESPIRATORY SYSTEM-Bilateral Normal vesicular breath sounds present.
CVS-S1,S2 present, No additional murmurs
GIT-Tense, shifting dullness present, no organomegaly
CNS-Higher mental functions and cranial nerves, motor, sensory, cerebellar
examination normal.
Treatment given and hospital course:
With this clinical picture at presentation viral etiology was suspected and
the patient was evaluated accordingly. Dengue NS1 Ag, Plasmodium card test,
Smear for Malarial parasite, IgM Dengue ELISA, IgM Chikungunya ELISA was
done. IgM Dengue ELISA was positive. Patient was managed conservatively with
antipyretics, and plenty of oral fluids. Patient responds well and afebrile
for 2 days. He is being discharged in hemodynamically stable condition
Advice on discharge and follow-up:

Tab. PCM-500 mg SOS

Tab. pan-40 mg OD BBF x 5 DAYS
Plenty of oral fluid
FOLLOW UP IN MEDICINE OPD, ROOM NO 27,28 on TUE/FRI DAY.

Investigations:
Date
Hb(gm%)
HCT
RBC
Platelet Count(/mm3
TLC (/mm3)
Urea(mg%)
Cr(mg%)
Calcium
Na(mEq/L)
K(mEq/L)
Bilirubin(T)(mg%)

18/10/2016
14.1
42.6
4,21,000
15,000
4,500
45
0.8
2.6/1.34
147
4.5
0.3

21/10/2016
15.3
38.2
4,89,000
40,000
5,700
18
0.5
7.2
134
4.7
0.7

CHEST X-RAY-Normal Study

E.C.G-75/MIN,SINUS RYTHEM
Plasmodium card Test-Negtative
Smear for malarial parasite-Negative
ANTI-DENGUE IgM Ab by ELISA-positive
ANTI-Chickengunya IgM Ab by ELISA- Negative
BLOOD CULTURE-NEGATIVE
Urine C/S : Sterile
Urine R/M : R.B.C-nil
W.B.C-nil
Protein-nil

Junior Resident

Senior Resident
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