Viral pyrexia case
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A 50 year old female patient, farmer by occupation, came to casualty with chief complaints of fever since five days, vomiting since two days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic five days back and she began farming like every other day but later that day in the evening she developed fever which was high grade, intermittent in nature and associated with chills and rigors. It was relieved temporarily on medications. Patient also had 2 episodes of vomiting since two days which was non projectile and non bilious. The vomit was not blood stained, odour-less. Patient also passed dark colored stools since last night. Patient complains of backache since last night.
PAST HISTORY:
No similar complaints are seen in the past. Patient is not a known case of Diabetes Mellitus, Tuberculosis, Asthma, CVD, Hypertension, Epilepsy and Thyroid disorders.
FAMILY HISTORY:
The patient's son developed similar complaints since four days.
PERSONAL HISTORY:
Diet is mixed, appetite is normal, sleep is adequate, bowel and bladder movements are regular. No known allergies. Non smoker and does not consume alcohol. Not any kind of medications.
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative. Well oriented to time, place and person. Moderately built and moderately nourished.
There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.
Vitals --- BP: 130/70 mmHg PR: 76 bpm Temp: afebrile RR: 18 cpm
SYSTEMIC EXAMINATION:
Cardiovascular: S1, S2 heard Respiratory: NVBS + CNS: NAD
INVESTIGATIONS:
Day 1 investigations— 20.11.2022
Observations made since day 1 to day 2 are there is gradual decrease in the platelet count from 90,000 to 36,000.
PROVISIONAL DIAGNOSIS:
Viral pyrexia with thrombocytopenia?! -------- Dengue?!
MANAGEMENT:
Patient is on i.v fluids and anti-pyretics as of now.
UPDATE: DAY 4 --- 23.11.2022
PATIENT MANAGEMENT UPDATE:
Patient is on i.v fluids, neomol for backache, metformin for diabetes which has been diagnosed a couple of days back..
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