Case history-2

 August 23,2021 

 

Date of admission:August 20,2021 


A 35 year old men presented to the Opd with the complaint of fever since 5days ,loose stools -6episodes ,4days back .


HISTORY OF PRESENT ILLNESS :Patient was apparently asymptomatic 5days ago and then he developed fever -low grade intermittent ,relieved on taking medication not a/w chills ,riger .Loose stools -6episodes 4days Ago which subsided now .stools were non watery ,not blood stained .No h/o vomitings ,pain abdomen chest pain ,palpitations,sob ,cough ,cold ,bleeding manifestations ,bleeding gums ,purpura .


HISTORY OF PAST ILLNESS :

Not a k/c/o DM/HTN

Br asthma /TB/EPILEPSY 

Plt count :

19th -64k

20th -11am -30k 

            6pm -25k

21st-12k 


PERSONAL HISTORY:

Normal appetite ,the patient is non -vegetarian ,regular bowel movement,normal micturation ,addictions -occasionally ,normal sleep .


FAMILY HISTORY :

No history of diabetes mellitus ,hypertension,Heart disease,stroke ,cancers ,tuberculosis,asthma .


GENERAL EXAMINATION:

The patient is conscious,coherent ,cooperative.

No Palar 

No clubbing 

No cyanosis 

No pedal edema 


VITALS :

Temp :febrile 

Pulse rate :82/min 

Bp:120/80mm /Hg



SYSTEMIC EXAMINATION:

Cardiovascular system :

No thrills 

No cardiac murmures-s1,s2+

Respiratory system :

No dysponea 

No wheeze

Position of trachea :central 

Breath sounds -vesicular 

Abdomen :

Shape of abdomen -scaphoid 

No tenderness 

No palpable mass 

Hernial orifices -normal 

No free fluid 

No bruits 

Bowel sounds -yes 

CNS :

Conscious 

Normal speech 

No neck stiffness 

No kernings sign 


INVESTIGATIONS: 

21/8/21

      HBsAg:

HIV1/2 rapid test :
Dengue NS1antigen ,IgM &IgG test :


              Anti HCV ANTIBODIES -rapid 
Hemogram -22/8/21
Haemoglobin -15.5gm/dl 
Toatal count -4,000cells/column 
Neutrophils-45%
Lymphocytes-44%
Eosinophils-4%
Monocytes -7%
Basophils -0
Platelet count -25klakh/cu.mm
Smear -normocytic normochromic with thrombocytopenia.
Hemogram -23/8/21
Haemoglobin -14.5gm/dl
Toatal count -4000 cells /column 
Neutrophils-38%
Lymphocytes-48%
Eosinophils-4%
Monocytes-10%
Basophils -0
Platelet count -30k lakhs/cu.mm
Smear -normocytic normochromic with relative lymphocytisis and thrombocytopenia.

Ultrasound report :

ECG REPORT :
Provisional diagnosis: Viral Pyrexia with Thrombocytopenia  (dengue fever )

Treatment given :
-Plenty of oral fluids 
-IVF -2times Ns}@75ml/hr
          2times Rl }@75ml/hr 
-Inj PANTOP 40 mg IV OD 
-Temp charting 4th hrly &Tepid sponging 
-Tab PCM 650mg PO TID 
-W/F Bleeding manifestations-postural hypotension.

Treatment is followed daily till the platelet count come to normal .


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