General medicine case-2

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Date of admission: 21/08/21

Cheif complaints:-

A 26 year's male patient bought to the casuality with history of fever since 5days.

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 15 days back. Then he complaints of cough and fever which was insidious in onset ,low grade, intermittent,not associated with chills & rigor which relieved upon taking medication.

Again 4 days back patient complaints about continuous fever not associated with chills and rigor and not reliving upon taking medication.

From 3 days patient complaints about abdominal tenderness.

On health check up there was reduced platelet count to 23000 cu/mm.

HISTORY OF PAST ILLNESS:-

No history of similar complaints in the past.

No history of any surgery.

No history of any fever.

No history of any associated symptoms

No history of epilepsy, bronchial asthama.

PERSONAL HISTORY:

Diet: mixed 

Appetite: normal

Sleep: adequate 

Does not smoke or consume alcohol. 

FAMILY HISTORY:-

Patients father was known case of diabetes and B.P 

No history of cancer.

No history of hereditary symptoms. 

GENERAL EXAMINATION:-

Patient is conscious, coherent, cooperative.

No pallor,clubbing,koilonychia and lymphadenopathy 

VITALS :-

Temperature: 

Pulse rate: 80bpm

Respiratory rate: 17 breaths

BP : 100/80 mmHg

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM:-

Chest wall is bilaterally symmetrical

No precordial bulge 

No visible pulsations, engorged veins,scars and sinues.

PALPATION

Apex beat : felt in the left 5th intercostal space in mid clavicular line.

AUSCULTATION

S1 and S2 heard

RESPIRATORY SYSTEM:-

Position of trachea - central

Bilateral air entry : +

Normal vesicular breath sounds - heard 

PER ABDOMEN

Abdomen distended,soft and non tender.

Bowel sounds heard.

No palpable mass or free fluid.

CENTRAL NERVOUS SYSTEM:-

Patient is conscious. 

Speech : normal 

No signs of meningeal irritation 

Sensory and motor reflexes: intact 

PROVISINAL DIAGNOSIS:-

Thrombocytopenia- Dengue fever  

INVESTIGATIONS:- 

Hemogram 

22/08/2021- 6.12 am

22/08/2021- 5.16 pm 

22/08/2021- 7.30 am

Anti-HCV Antibodies test :  Rapid 

HbsAg- Rapid test : 

HIV 1/2 RAPID test : 

ECG : 

TREATMENT:- 

1) IVF - NS } @100ml/hr

              R2 } @ 100ml/hr 

2) Tab. Dolo 650mg /PO/ TID  

     check temperature before giving Dolo

3) Inj. NEOMAL 1gm/IV/SOS 

4) Bp/ PR/ Spo2/RR monitoring every 4tg hrly

5) Temperature charting 2nd hrly 

6) Watch for bleeding manifestations 

7) Inj. PANTOP 40mg IV OD 

8) Plenty of oral fluids 

9) Inj. ZOFER 4mg IV SOS