27 M VIRAL PYREXIA WITH THROMBOCYTOPENIA
A 27 yr male patient came with complaint of fever since 3 days which is of high grade and continuous type, aggrevated during night and relieved on taking medication and associated with chills since 2 days.
Patient says he had back ache and joint pains in lower limb associated with fever.
C/o generalised weakness since 4 days.
No H/O headache
No h/o vomitings
No c/o cold, cough
No H/O burning micturition
No h/o hematuria
No H/O diarrhoea, constipation
No H/O abdominal pain & tenderness
No H/O bleeding manifestations and rash
No H/O palpitations,chest pain, syncopal attacks
No H/O loss of apetite, decreased sleep
No H/O loss of consciousness/fatigue/weakness
PAST HISTORY:
Not a K/C/O Diabetes, Hypertension, Asthma, Epilepsy,T.B,CVA,CAD
No past history of similar complaints
No past history of hospitilization or surgery
FAMILY HISTORY:
No H/O Diabetes, Hypertension, Asthma, Epilepsy, Tuberculosis, CVA, CAD.
PERSONAL HISTORY:
Diet :mixed
Sleep :adequate
Bowel and bladder :regular
Appetite: normal
Micturition :normal
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative
No pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema
VITALS:
Temperature:99 F
Pulse:82bpm
Blood pressure:130/90mm of hg
Respiratory rate:22 cpm
SpO2 :98 %at room air
SYSTEMIC EXAMINATION:
CVS EXAMINATION:
s1,s2 heard
No murmurs
RESPIRATORY SYSTEM EXAMINATION :
Bilateral air entry present
Normal vesicular breath sounds heard
No added sounds heard
PER ABDOMEN EXAMINATION:
Scaphoid abdomen
No tenderness
No palpable mass
Bowel sounds heard.
Liver and spleen not palpable.
CNS EXAMINATION:
No abnormality detected.
INVESTIGATION:
DAY 1:
DAY 2:
DAY 3:
PROVISIONAL DIAGNOSIS:
Viral pyrexia with thrombocytopenia
Dengue NS1 antigen positive
TREATMENT:
IV FLUIDS : NS - 1, DNS - 1, RL - 1 @ 100 ml/hr
Tab. Doxycycline - 100 mg BD
Tab. Paracetamol - 650 mg SOS
Tab. Pantoprazole - 40 mg OD
Inj. Zofer - 4 mg IV
Input/ output charting, monitoring of vitals and bleeding manifestations was done.
Comments
Post a Comment