26 yr old male with viral pyrexia and thrombocytopenia
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Case presentation:
A 26 yr old male patient came to OPD on 1/12/2020 at 12:45pm with cheif complaints of fever since 10 days, subsided on its own and not associated with chills
Again 7 days back patient complaint of fever for 3 days associated with chills, relieved on medication ,diurnal variation present - increased during night associated with vomiting 2 episodes and vomitus contains food particles ,non bilious not associated with blood
c/o generalized weakness and myalgia since 7 days
c/o malena since 2 days
c/o cough since 15 days associated with sputum
sputum is whitish,mucoid,non foul smelly,not associated with blood
No c/o cold
No H/O burning micturition,no hematuria
No H/O diarrhoea, constipation
No H/O abdominal pain & tenderness
No H/O palpitations,chest pain, syncopal attacks
PAST HISTORY
Not a K/C/O Diabetes, Hypertension, Asthma, Epilepsy,T.B,CVA,CAD
FAMILY HISTORY
No history of diabetes , hypertension, asthama ,
Asthama, epilepsy, CAD, CA
PERSONAL HISTORY
k/C/O alcoholic since 9 years(Thrice a week)1 beer once
H/O smoking since 7 years (occasionally)
Abstinence since 1year
Diet :mixed
Sleep :adequate
Bowel and bladder :regular
Appetite:decreased
GENERAL EXAMINATION
PT is conscious , coherent , cooperative
no pallor,icterus,cyanosis,clubbing,
lymphadenopathy,no edema
Vitals:
Temperature:99 F
Pulse:90bpm
Blood pressure:110/70mm of hg
Respiratory rate:22 cpm
SpO2:98 %at room air
CVS EXAMINATION
S1S2 heard
No murmurs
RESPIRATORY SYSTEM
Bilateral air entry present, no added sounds
PER ABDOMEN
Scaphoid abdomen,soft and no tenderness,no mass
No organomegaly
CNS
No abnormality detected
INVESTIGATIONS
DAY 1
HAEMOGRAM
CUE
CHEST X RAY
ECG
LFT
RFT
PT ,INR
DAY 2
At 6am
DAY 3
HAEMOGRAM
At 6 am
At 6pm
LIPID PROFILE
CHEST X RAY
DAY 4
At 6pm
HBA1c
DAY 5
At 6 am
PROVISIONAL DIAGNOSIS
Viral pyrexia with thrombocytopenia
NS1 antigen positive
TREATMENT
IV Fluids 1 NS , 1DNS, 1RL at 100ml/hr
INJ PAN 40 mg IV OD
INJ ZOFER 4mg IV OD
INJ OPTINEURON 1amp in 100ml NS IV OD
TAB DOLO 650 mg SOS
INJ NEOMOL IV Stat if Temp> 101F
TEPID SPONGING
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