A 23 year old female with low platelet count

 A 23 year old female resident of Miryalguda home maker by occupation came with chief complaints of fever since 11 days.

HOPI 

Patient was apparently asymptomatic 7 days back.

Then she developed fever since 7 days which was high grade intermittent and associated with chills and rigor

She went to a local hospital and took medication and the fever subsided.

Then after 3 days she again had fever for which she came our hospital and widal test was done and it was negative .

She also done the test at local hospital and it was positive for dengue and they visited a hospital in Nalgonda and was told her platelet count was low and then they went to Osmania hospital because of some personal problem they came our hospital on 14/08/2022

PAST HISTORY

No similar complaints in the past

Not a known case of Diabetes Hypertension Asthma TB Epilepsy

History of hypothyroidism during third pregnancy and it bacame normal after delivery

History of Tubectomy and LSCS 3 months back 

FAMILY HISTORY No significant family history

PERSONAL HISTORY

Diet mixed

Appetite Normal

Sleep adequate 

Bowel and bladder Regular

Addictions No addictions

DRUG HISTORY No history of allergy to any kind of drugs

GENERAL EXAMINATION


Patient was conscious coherent and cooperative

Moderately built and nourished 

pallor present

No, Icterus, Cyanosis, Clubbing, generalized lymphadenopathy and edema 


Vitals

Temperature Afebrile 

RR 20 cpm

PR 90

BP 110/90

GRBS  106gm/dl







Systemic Examination


RESPIRATORY SYSTEM EXAMINATION 

Inspection:


Symmetrical chest seen

No scars and sinuses 

Trachea central

Palpation:


Inspectory findings are confirmed




Percussion: 




Resonant note present in all lung areas




Auscultation:




Breath sounds heard. 




PER ABDOMEN 




Inspection: 




No Abdominal distension 




No scars, sinuses, mass visible




Palpation:




Inspectory findings are confirmed 




No local rise of temperature




Tenderness absent


Mild hepatomegaly and mild spleenomegaly




Auscultation




: Normal bowel sounds heard




No bruit heard




CARDIOVASCULAR SYSTEM EXAMINATION 




Inspection : Bilaterally symmetrical chest present 




No scars, sinuses






Palpation:




Inspectory findings are confirmed




Apex beat normal




On Auscultation : 




S1 S2 heard




No murmurs or additional heart sounds




CENTRAL NERVOUS SYSTEM EXAMINATION 




Higher mental functions intact 




Cranial nerves intact 




No focal neurological defecits  








 












    







   PROVISIONAL DIAGNOSIS 

Viral pyrexia

TREATMENT 

Tab Doxy 100 mg PO BD 

Tab DOLO 650 mg PO SOS 

I PCM 1 gm IV SOS 

I OPTINEURON 1 Ampoule IV OD 

Inj Zofer 4 mg IV SOS

IV Normal saline and Ringer lactate 75ml/hr







Comments

Post a Comment

Popular posts from this blog

A 22 yr old female with generalized weakness and easy fatiguability since 2 months

Image
 A 22 yr old female who is a student came with complaints of generalized weakness and easy fatiguability since 2 months  History of Presenting illness Pt was apparently asymptomatic 5  years back then she started to have desire to eat non edible material and went to the hospital and was diagnosed with Anemia (Hb 4gm/dl) and 2 units of PRBC transfusion was done Now since 2 months she is complaining of easy fatiguability with generalized weakness  C/o SOB(grade ll-III) insidious in onset, gradually progressive to grade III,c/o exertional dyspnea  No c/o chest pain, palpitations, orthopnea,pnd  No c/o fever,loose stools, vomitings PAST HISTORY H/o similar complaints in the past H/o two PRBC transfusion N/k/c/o diabetes HTN TB Asthma Epilepsy thyroid disorders  PERSONAL HISTORY Diet  Mixed Appetite normal Sleep adequate Bowel and bladder  regular Addictions No  Daily routine  Pt wakes up around 7 am takes breakfast and goes for coaching institute and comes back at 6 am and takes dinner at
Read more

65 year old male with cough since 2 months and fever since 15 days and chest pain since 1 day

Image
 This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome. I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan. A 65 year old male resident of chityal labourer by occupation came with chief complaints of fever, cough with sputum since 15 days and chest pain from  4pm of  23/06/2023 HISTORY OF PRE
Read more

A 45 year old female patient presented with chief complaints of fever and shortness of breath

Image
 A 45 year old female patient resident of Chinthapally who is a agricultural labourer by occupation came with chief complaints of shortness of breath and fever since 15 days  HOPI  Patient was apparently asymptomatic 15 days back. Then she developed fever since 15 days associated with chills .She also has shortness of breath since 15 days. 15 days ago she had fever for which she went to the local hospital and got treated. After the treatment the fever subsided and she developed fever again for  which she went to the local hospital where she was diagnosed with thrombocytopenia.Then they came to Kims 3 days ago for the treatment of thrombocytopenia. No history of nausea vomiting. Past history :No history of Hypertension, tuberculosis, asthma. Personal history Diet:mixed  appetite : normal Bowel and bladder: regular Sleep : adequate Addictions:no addiction Family history:no relevant family history General examination: Patient is conscious, coherent and non-cooperative. Moderately built an
Read more