fever projr 202341050 21/m

 Diagnosis

VIRAL PYREXIA WITH THROMBOCYTOPENIA

Case History and Clinical Findings

C/O FEVER SINCE 5 DAYS

HOPI-

PATIENT WAS APPARENTLY ASYMPTOMATIC 5 DAYS BACK THEN DEVELOPED HIGH GRADE FEVER, ASSOCIATED WITH CHILLS AND RIGORS, NO DIURNAL VARIATION, RELIEVED WITH MEDICATION.

C/O LOOSE STOOLS 8-10 EPISODES TODAY AND AROUND 4 EPISODES YESTERDAY, WATERY IN CONSISTENCY, NON-FOULSMELLING, NON BLOOD STAINED.

NO C/O RASH/HEMATURIA/BLEEDING MANIFESTATIONS/PETTECHIAE

RETRO ORBITAL PAIN+, LOSS OF APPETITE+

NO C/O SOB/PALPITATIONS/ CHEST PAIN/ ORTHOPNEA/ PND

PAST HISTORY-

NOT A K/C/O HTN,DM,EPILEPSY, THYROID DISORDERS

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE WELL ORIENTED TO TIME, PLACE, PERSON.

MODERATELY BUILT AND NOURISHED.

NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS, LYMPHEDENOPATHY, EDEMA


TEMPEARTURE: 102 F

PULSE RATE: 110 BPM

BLOOD PRESSURE: 110/70 MMHG

RESPIRATORY RATE: 16 CPM

SPO2: 98% @ RA

CVS: S1, S2 HEARD, NO MURMURS

RS: BAE +, NVBS

P/A: SOFT, NON TENDER, NO ORGANOMEGALY

CNS: NFND

REFLEXES:

BICEPS TRICEPS SUPIANTOR KNEE ANKLE

RIGHT 2+ 2+ 1+ 2+ 2+

LEFT 2+ 2+ 1+ 2+ 2+

Investigation

HBsAg-RAPID12-09-2023 08:23:PM Negative

Anti HCV Antibodies - RAPID12-09-2023 08:23:PM Non Reactive

BLOOD UREA12-09-2023 08:23:PM

SERUM CREATININE12-09-2023 08:23:PM

1.0 mg/dl1.3-0.9 mg/dl26 mg/dl

42-12 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM

12-09-2023 08:23:PM SODIUM136 mEq/L

145-136 mEq/L

POTASSIUM4.3 mEq/L

5.1-3.5 mEq/L

CHLORIDE

99 mEq/L98-107 mEq/L

CALCIUM IONIZED

1.20 mmol/Lmmol/L

COMPLETE URINE EXAMINATION (CUE) 12-09-2023 08:23:PM

COLOUR

Pale yellow


APPEARANCE

Clear

REACTION

Acidic

SP.GRAVITY

1.010

ALBUMIN

Nil

SUGAR

Nil

BILE SALTS

Nil

BILE PIGMENTS

Nil

PUS CELLS

2-3

EPITHELIAL CELLS

1-2

RED BLOOD CELLS

Nil

CRYSTALS

Nil

CASTS

Nil

AMORPHOUS DEPOSITS

Absent

OTHERS

Nil

HAEMOGRAM 12/9/23

HB-13.2 GM/DL

TLC-2500 CELLS/CUMM

RBC-4.66 MILLIONS/CUMM

PLATELET-1.12 LAKHS/CUMM


Treatment Given(Enter only Generic Name)

IV FLUIDS 2NS@ 75ML/HR; 1 RL

INJ. NEOMOL 1GM IV/SOS

T.DOLO 650MG PO/BD

T.SPOROLAC-DS PO/TID

INJ.DOXYCYCLINE 100MG IV/BD

Advice at Discharge

PLENTY OF ORAL FLUIDS

T.DOLO 650MG PO/SOS

T.SPOROLAC-DS PO/SOS




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