Case history- 11

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A 13 year old male patient came to the  OPD with chief complaints of fever associated with chills , vomitings, loose stools and giddiness since 4 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 4 days  back  and then he noticed fever associated with chills, vomitings of food contents 2- 3 episodes/ day and giddiness since 4 days.

4 days back he noticed loose stools of 5 episodes.

 No history of burning micturition.

PAST HISTORY:

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

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: 98.2 °F

Blood pressure: 80/60 mm Hg

Pulse rate:  68 beats / min

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

No thrills 

S1 and S2 sounds are heard 

No cardiac murmurs

RESPIRATORY SYSTEM:

Dyspnoea- no

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

                           ECG

DIAGNOSIS:

Dengue fever with thrombocytopenia 

TREATMENT:

1. Inj. PANTOP IV 40mg OD

2. Inj. ZOFER 4mg IV BD

3.Tab. DOLO 650mg SOS 

4. ORS sachets in 1 litre water 200ml after each stool

5. Tab. SPOROLAC - DS 1 tab. BD

6  Syp. POTCHLOR 10 ml in 1 glass water BD

7. Plenty of oral fluids