Case history- 8

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A 20 year old male patient came to the OPD with chief complaints of  fever since 5 days.

HISTORY OF PRESENT ILLNESS:

 

Patient was apparently asymptomatic 5 days back and then he noticed high grade fever not associated with chills and rigors.

No history of vomitings, loose stools.

No history of  shortness of breath, cough.

No history of  burning micturition. 

PAST HISTORY:

No history of diabetes, hypertension, CAD, asthma, TB, epilepsy. 

No history of any surgeries in the past. 

No hematuria, malena, bleeding gums, hematemesis.

PERSONAL HISTORY:

Appetite: normal 

Diet: mixed 

Sleep: adequate 

Bowel and bladder movements: regular 

Micturition: normal 

Addictions: no

FAMILY HISTORY:

There is no history of similar complaints in the family. 

TREATMENT HISTORY:

Patient had not undergone any treatment prior. He is not allergic to any known drugs.

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative and well oriented to time, place and person. 

There is no signs of pallor, icterus, cyanosis, clubbing , lymphadenopathy and edema. 

VITALS:

Temperature: 99°F

Blood pressure: 110/90 mm Hg

Respiratory rate: 18 / min

Spo2: 98% at room temperature 

Pulse rate: 98 beats/ min 

GRBS: 126 mg%

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

No thrills

S1 and S2 sounds are heard 

No cardiac murmurs

RESPIRATORY SYSTEM:

No dyspnoea

No wheezing  sounds 

Position of trachea- central 

Breath sounds- vesicular

ABDOMEN:

Shape of abdomen- scaphoid 

Tenderness- no 

Palpable mass- no 

Hernial orifices- normal 

Free fluid- no 

Bruits- no 

Liver- not palpable 

Spleen- not palpable 

Bowel sounds- yes 

CENTRAL NERVOUS SYSTEM:

Level of consciousness : conscious 

Speech: normal 

Signs of meningeal irritation 

          Neck stiffness- no 

Cranial nerves- normal 

Motor system- normal 

Sensory system- normal 

INVESTIGATIONS:

                 HEMOGRAM 

               SERUM CREATININE 

                 SERUM ELECTROLYTES 

                

                LIVER FUNCTION TEST 

                  

           

          COMPLETE URINE EXAMINATION 

               BLOOD SUGAR- RANDOM 

          

          ANTI HCV ANTIBODIES- RAPID

     

            HBsAg- RAPID 

                   HIV 1/2  RAPID TEST 

                            ECG

DIAGNOSIS:

Viral pyrexia with thrombocytopenia 

          Dengue NS1 positive 

TREATMENT:

1. Inj.PANTOP 40mg IV OD

2. Plenty of oral fluids 

3. Inj. OPTINEURON 100ml IV OD

4. Inj. NEOMOL 1 gm IV SOS

5. Tab. DOLO 650mg SOS

6. Tab. DOXY 100mg BD