Case history - 6

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A 20 year old male patient came to the casuality with chief complaint of fever since 5 days.

History of present illness : 

Patient was apparently asymptomatic  before 5 days then he developed fever . 

Fever is not associated with chills and rigors.

No history of loose stools , vomitings.

No history of  burning micturition , shortness of breath , cough.

No history of hematuria , Malena , bleeding gums.

Past history : 

Patient is not a known case of diabetes , hypertension, CAD ,  asthma ,TB, epilepsy.

No history of surgeries in the past.

Personal history : 

Diet - mixed 

Appetite - normal 

Sleep - adequate 

Bowel and bladder movements - regular 

Addictions - Non alcoholic

                       Non smoker 

Family history : 

No history of similar complaints in the family.

General examination : 

Patient is conscious , coherent , cooperative and we'll orientated to time , place and person .

Pallor - absent 

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy - absent 

Edema - absent 

VITALS : 

Temperature - 99°F

Blood pressure - 110/90 mm Hg 

Respiratory rate - 18 / min 

Pulse rate - 98 beats / min

Sp02 - 98% at room temperature  

SYSTEMIC EXAMINATION : 

Cardiovascular system : 

No thrills 

S1 S2  heard 

No cardiac murmurs 

Respiratory system : 

No dyspnoea 

No wheeze 

Position of trachea - central 

Breath sounds - vesicular 

Abdomen  : 

Shape of abdomen - scaphoid 

Tenderness - no 

Free fluid - no 

Bruits - no 

Central nervous system ;

Level of consciousness - conscious 

Speech - normal 

No neck stiffness  

INVESTIGATIONS : 

Diagnosis : 

Viral pyrexia with thrombocytopenia 

Dengue NS1 - positive  

Treatment : 

Inj .PANTOP 

Inj . OPTINEURON 

Inj . NEOMOL 

Tab DOLO 

Tab DOXY 

Plenty of oral fluids