23yr Male with fever with thrombocytopenia
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PRESENTING COMPLAINTS:
Fever since 4days.
Epigastric pain since 1day.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 4days ago, then he got high grade fever, continuous type ,relieving on medication.
Associated with chills and rigor.
No H/O cold, cough
No H/O nausea, vomitings, headache.
No H/O burning micturation.
No H/O bleeding manifestations.
HISTORY OF PAST ILLNESS:
No similar complaints in the past.
Not a K/C/O HTN,DM,TB, Epilepsy,Asthma,CAD
PERSONAL HISTORY:
Diet- Mixed
Appetite- Normal
Sleep- Adequate
Bowel and Bladder movements- Normal
FAMILY HISTORY:
No significant family history.
GENERAL EXAMINATION:
No Pallor, Icterus, Clubbing,Cyanosis, Lymphadenopathy, Pedal Edema.
Temperature- 97.3F
BP- 80/50mmhg
PR- 94bpm
RR- 18cpm
P/A- soft, tenderness over epigastric region
Spo2- 96%@room air
GRBS- 303@ admission
CARDIOVASCULAR SYSTEM:
S1,S2 heard
No murmurs
RESPIRATORY SYSTEM:
Upper limb Lower limb
Right Left Right Left
Tone: Normal Normal Normal Normal
Power: 5/5 5/5 5/5 5/5
Reflexes: Right Left
Biceps + +
Triceps + +
Supinator + +
Knee + +
Ankle + +
Plantar Flexion Flexion
ECG:
CHEST X-RAY :
USG ABDOMEN AND PELVIS:
LAB INVESTIGATIONS:
On Day1 of admission:
On Day2 of admission:
PROVISIONAL DIAGNOSIS:
Viral Pyrexia (Dengue fever)with thrombocytopenia.
Normocytic Normochromic Anemia.
?Denovo DM II
?AKI
TREATMENT:
1) IV fluids 2 NS bolus IV/STAT
2) TAB. DOLO 650mg PO/TID
3) TAB. DOXYCYCLINE 100mg PO/BD
4) TAB. PANTOP 40mg PO/OD
5) Plenty of oral fluids.
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