45 yr old female with fever and thrombocytopenia
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I have 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 diagnosis and treatment plan
CASE PRESENTATION
A 45year old female resident of gollapet housewife by occupation came to general medicine OPD ( 7/12/2022) with chief complaints of
•fever since 4 days associated with chills headache ,vomiting and body pains
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 8 days ago and then she developed low grade fever which is sudden in onset ,continuous, associated with chills at night ,head ache and bodypains. She also had double episodes of vomiting which was non bilious and non projectile and has food as content .
She suddenly had bilateral pricking pain and subsided after 30 min of taking PCM .
1 hour later she developed low grade fever suddenly associated with chills which was not subsided by medication.
Throbbing headache localized to bilateral temporal regions ,non radiating associated with nausea.
Then she visited a local hospital next morning, investigations were done and they were said to have low platelets (30,000) and diagnosed as dengue. Treatment given and came to our hospital for further management.
She came to our opd with complaints of
☆Recurrent fever with chills( which increased at night)
☆vomitings (more than 2 episodes per day ).
☆C/o pricking pain in both legs
No H/o of SOB, cough, cold, chest pain.
No H/o of giddiness
No H/o of burning micturition and abdominal pain
No H/o of loss of appetite
PAST HISTORY
Not K/C/O hypertension, diabetes mellitus, CAD, epilepsy, TB, asthma
Surgical history: 3 LSCS
blood transfusions : yes, post C/S 22 years ago (4 units )
PERSONAL HISTORY
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel and bladder movements: normal and regular
No addiction
No known allergies
FAMILY HISTORY
Not relevant
GENERAL EXAMINATION
patient is conscious, coherent, cooperative
Patient is malnourished
No pallor, icterus, cyanosis, clubbing of fingers, lymphadenopathy, edema


Vitals:
Temperature: 98 °F
Blood pressure: 110/70 mmHg
Pulse rate: 100bpm
GRBS: 120mg/dl
SpO2: 99%
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM:
S1 and S2 +
No murmurs heard
RESPIRATORY SYSTEM
No dysnea, wheez,
Position of trachea: central
Breath sounds: vesicular
ABDOMEN
No tenderness, palpable mass
No distention
No organomegaly

PROVISIONAL DIAGNOSIS:
Viral pyrexia with thrombocytopenia
INVESTIGATIONS:









TREATMENT
1) Plenty if oral fluids
2) Ivf 20 normal saline, 20 RL@75ml/hr
3) Inj Zofer 4mg/IV/SOS
4) Inj PAN 40mg/IV/OD @ 8am
5)W/F orthostatic hypotension bleeding manifestation
6) T.PCM 650mg PO SOS
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