Case history - 9

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  A 19 year old male came to casuality with chief complaint of fever , cough , nausea since since 3 days . 

History of present illness : 

Patient was apparently well before  3 days back then he developed  high grade fever with chills and it is intermittent  , cough .

Patient also complaints of nausea , generalized body pains .

And also burning micturition and constipation since  3 days.

No history of vomiting. 

No history of diarrhoea. 

Past history :

No history of diabetic mellitus .

No history of hypertension.

No history of CAD , Tuberculosis , Asthma.

Personal history : 

Appetite -  decreased 

Diet - mixed 

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, moderately built 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 : 120/80 mmHg 

Pulse rate : 108 / min 

SpO2 : 98% 

SYSTEMIC examination : 

Cardiovascular system : 

No thrills 

S1 S2  heard 

No cardiac murmurs 

Respiratory system : 

No dyspnoea  

No wheeze 

Breath sounds - vesicular 

Abdomen : 

Shape of abdomen - normal 

No tenderness 

No palpable mass 

Free fluid - no 

No bruits 

Liver - not palpable 

Spleen - not palpable 

Central nervous system : 

Level of consciousness - conscious 

Speech - normal 

Neck stiffness : no 

Investigations : 

Provisional Diagnosis : 

Dengue fever with mild thrombocytopenia .

Treatment : 

IVF - NS ,RL ,DNS - continuous @ 100 ml / hr 

Inj PANTOP -40 mg - IV  -OD 

Inj ZOFER - 4 mg - IV 

Syp Cremaffin - 10 ml 

Syp Grilinctus - 10 ml - BD 

Inj NEOMOL - 1 gm - IV 

Tab DOLO - 650 mg - TID