Case history-4

 30/9/21

Date of admission:29/09/21


A 24 yr old female presented to the opd with the chief complaint of fever from the past 4 days ,left hypochondriac pain since 4 days and headache since 4 days .


HISTORH OF PRESENT ILLNESS:

Patient was apparently asymptomatic 4days back and then developed fever from past 4days,left hypochondriac pain since 4days and is not associated with vomitings ,irregular bowel movements and burning micturaton .


HISTORY OF PAST ILLNESS :

Outside platelet count -80,000cells/cumm 

No past history of K/C/O HTN,DM,TB,asthma, epilepsy .


PERSONAL HISTORY:

Married ,normal appetite-lost ,non-vegetarian,regular bowel movement,normal micturation,no known allergies ,no addictions.


FAMILY HISTORY:

Their is family history of diabetes ,hypertension,and no history of Heart disease,stroke,cancers ,tuberculosis,asthma.


MENSTRUAL HISTORY:

Regular menstrual cycle .


GENERAL EXAMINATION:

The patient is conscious, coherent and cooperative.

No Palar 

No icterus 

No clubbing 

No cyanosis 

No lymphadenopathy 

No oedema 

No malnutrition 

No dehydration 


VITALS:

Temp :febrile 

Pulse rate :74bpm 

BP:80/60mmhg 

Respiratory rate :16cpm 

Grbs:92mg/dl 


SYSTEMIC EXAMINATION :

CVS:

No thrills 

Cardiac sounds :s1,s2 heard 

No cardiac murmurs 


RESPIRATORY SYSTEM :

No dysponea 

No wheeze 

Position of trachea :central 

Breath sounds :vesicular 

ABDOMEN :

Shape of abdomen:scaphoid 

Tenderness:diffuse 

No palpable mass 

Hernial orifices -normal 

No free fluid 

No bruits 

Liver ,spleen -not palpable 

Bowel sounds -yes 

CNS :

Conscious 

Normal speech

No neck stiffness 

No kernings signs 

Cranial nerves ,motor system ,sensory system -normal 

Glasgow scale -15/15

CEREBRAL SIGNS:

Finger -nose in -coordination-yes 

Knee-heel in-coordination-yes


INVESTIGATIONS:

Hemogram:9.3gm/dl

Total count :4,400cells/cumm

Neutrophils:43%

Lymphocytes:45%

Eosinophils:2%

Monocytes:10%

Basophils-00%

Pcv:29.7vol%

MCV:69.9fl

MCH:21.9pg

MCHC-31.3%

Rbc count -4.25million/cumm

Platelet count-36,000lakh/cu.mm

Anti-HCV antibiodies -non reactive 

Serum creatinine -0.6mg/dl

Total bilirubin -0.42mg/dl 

Direct bilirubin-0.16mg/dl

SGOT -50IU/L

SGPT-44IU/L

Alkaline phosphate-118IU/L

Total proteins -5.3gm/dl

Albumin -3.3gm/dl 

A/G ratio-1.69


HBsAg-rapid :negative 

BLOOD UREA -15mg/dl 


SERUM ELECTROLYTES:

Sodium -140mEq/L

Potassium-4.4mEq/L

Chloride-102mEq/L



TREATMENT GIVEN:

29/9/21:

-IVF NS RL @150 ML/HR 

-inj.NEOMAL 1GM IV/SOS 

-inj pantop 40mg PO/OD 

-inj zofer 4mg IV/SOS 

-tab.pcm 650mg PO/SOS 

-monitor vitals 2hrs daily 

-W/F bleeding manifestations

-strict I/O  and temp monitoring

30/9/21:

-IVF NS RL @150 ML/HR 

-inj pantop 40mg PO/OD 

-inj zofer 4mg IV/SOS 

-tab.pcm 650mg PO/SOS 

-monitor vitals 2hrs daily 

-W/F bleeding manifestations

-strict I/O  and temp monitoring

Same treatment is followed for next four days .

PROVISIONAL DIAGNOSIS:viral Pyrexia 

FINAL DIAGNOSIS: viral pyrexia with thrombocytopenia with serositis .

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