Case history-7
VIRAL PYREXIA WITH THROMBOCYTOPENIA
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A 45 yr old male presented to the opd with the chief complaint of fever and chills since 4days .No h/o vomitongs ,loose stools .
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 4days back and then he gradually developed muscle cramps and cough initially .
No complaint of chest pain ,blurring of vision .
HISTORY OF PAST ILLNESS:
Not a k/c/o HTN/DM/TB /ASTHMA /CAV/CDA
PERSONAL HISTORY:
Married ,normal appetite,vegetarian,regular bowel movement,micturation -normal ,no known allergies ,addictions occasionally.
FAMILY HISTORY:
No history of diabetes, hypertension, heart disease, stroke, asthma, tuberculosis,cancers .
General examination:
The patient is conscious, coherent, cooperative.
Palar-present
No cyanosis
No lymphadenopathy
No malnutrition
No dehydration
No clubbing
No icterus
No Edema
VITALS :
Temp :afebrile
Pulse rate:70/min
Respiratory rate:18cpm
Bp:130/90 mm/hg
Spo2-99%of o2
SYSTEMIC EXAMINATION:
CVS :
No thrills
No cardiac murmurs
Cardiac sounds-s1,s2 heard
RESPIRATORY SYSTEM :
Dysponea-present
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
Liver ,spleen-not palpable
Bowel sounds -yes
CNS:
Conscious
Normal speech
No neck stiffness
No kernings signs
Cranial nerves ,motor and sensory system,glasgow scale -normal .
REFLEXES :
Plantars -flexor
CEREBRAL SIGNS:
No finger -nose in -coordination
No knee -heel in -coordination.
PROVISIONAL DIAGNOSIS:
Viral pyrexia with thrombocytopenia.
INVESTIGATIONS:
26/10/21
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