Case history-10
A 19yr OLD MALE WITH DENGUE THROMBOCYTOPENIA
Date of admission:8/12/21
A 19 yr old male came to the opd with the chief complaint of fever since three days and cough (dry) since three days .
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic three days ago and then developed high grade fever associated with chills ,intermittent since 3 days ,associatied with dry cough since 3 days and generalised bodypains since 2days and history of burning micturation since 3days ,nausea ,cold,neck pain ,and constipation since 3days .
HISTORY OF PAST ILLNESS:
No h/o vomitings ,loose stools
Not a k/c/o HTN/DM/TB /ASTHMA /CAV/CDA
PERSONAL HISTORY:
UnMarried ,normal appetite,non 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
malnutrition -present
No dehydration
No clubbing
No icterus
No Edema
VITALS :
Temp :afebrile
Pulse rate:108/min
Respiratory rate:18cpm
Bp:150/90mm/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 .
Provisional diagnosis:
Dengue fever with thrombocytopenia
INVESTIGATIONS:
8/12/21
TREATMENT:
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