A 23 yr old woman with decreased platelet count
A 23 yr old woman resident of Miryalguda home maker by occupation came with chief complaints of fever since 11 days.
HOPI
Patient was apparently asymptomatic 7 days back.
Then she developed fever since 7 days which was high grade intermittent and associated with chills and rigor
She went to a local hospital and took medication and the fever subsided.
Then after 3 days she again had fever for which she came our hospital and widal test was done and it was negative .
She also done the test at local hospital and it was positive for dengue and they visited a hospital in Nalgonda and was told her platelet count was low and then they went to Osmania hospital because of some personal problem they came our hospital on 14/08/2022
PAST HISTORY
No similar complaints in the past
Not a known case of Diabetes Hypertension Asthma TB Epilepsy
History of hypothyroidism during third pregnancy and it became normal after delivery
History of Tubectomy and LSCS 3 months back
FAMILY HISTORY No significant family history
PERSONAL HISTORY
Diet mixed
Appetite Normal
Sleep adequate
Bowel and bladder regular
Addictions No addictions
DRUG HISTORY No history of allergy to any kind of drugs
GENERAL EXAMINATION
Patient was conscious coherent and cooperative
Moderately built and nourished
pallor present
No, Icterus, Cyanosis, Clubbing, generalized lymphadenopathy and edema
Vitals
Temperature Afebrile
RR 20 cpm
PR 90
BP 110/90
GRBS 106gm/dl
Systemic Examination
RESPIRATORY SYSTEM EXAMINATION
Inspection:
Symmetrical chest seen
No scars and sinuses
Trachea central
Palpation:
Inspectory findings are confirmed
Percussion:
Resonant note present in all lung areas
Ascultation:
Breath sounds heard.
PER ABDOMEN
Inspection:
No Abdominal distension
No scars, sinuses, mass visible
Palpation:
Inspectory findings are confirmed
No local rise of temperature
Tenderness absent
Mild hepatomegaly and mild spleenomegaly
Auscultation
Normal bowel sounds heard
No bruit heard
CARDIOVASCULAR SYSTEM EXAMINATION
Inspection : Bilaterally symmetrical chest present
No scars, sinuses
Palpation:
Inspectory findings are confirmed
Apex beat normal
On Auscultation :
S1 S2 heard
No murmurs or additional heart sounds
CENTRAL NERVOUS SYSTEM EXAMINATION
Higher mental functions intact
Cranial nerves intact
No focal neurological defecits
INVESTIGATIONS
PROVISIONAL DIAGNOSIS
Viral pyrexia
TREATMENT
Tab Doxy 100 mg PO BD
Tab DOLO 650 mg PO SOS
I PCM 1 gm IV SOS
I OPTINEURON 1 Ampoule IV OD
Inj Zofer 4mg IV SOS
IV Normal saline and Ringer lactate 75ml/hr
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