A 18yr old male Fever with thrombocytopenia

 

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A 18yr old male Fever with thrombocytopenia

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 18 yr old male came to the OPD with chief complaints of

 -fever since 2 days

- vomiting’s since 2 days

-diarrhea  since 2 days

History of present illness:

Patient was apparently a symptomatic 2 days back then he developed fever of high grade with chills and rigor it was intermittent in nature which relieved on medication and was associated with generalised weakness

The fever was associated with nausea and vomitings 10 Episodes the content was food they were non bilious non foul smelling and non projectile

It was associated with loose stools 5 episodes

There is no history of cold, cough, headache, pain abdomen, burning micturition, petechiae, hemetemesis, malena, bleeding per rectum.

 

(The patient was taken to nearby hospital for above complaints and there they said his platlets count was low and was referred to our hospital)

 

Past history:

He is not a known case of HTN, DM, asthma, epilepsy, TB:

 

 

Personal history:

Diet:mixed

Appetite:normal

Sleep:adequate

Bowel and bladder: regular

Allergies: no known drug and food allergies

Addictions: no

 

Family history:

Insignificant

 

General examination

Patient was conscious, cooperative and coherent and was well oriented to time , place, person.

He is moderately built and moderately nourished

Vitals

Temperature: afebrile

Pulse rate:76bpm

Blood pressure:120/80mmhg

Respiratory rate :12cpm

SpO2:98%

 

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing : absent

Lymphadenopathy: absent

Edema: absent

 

Systemic examination

Respiratory system: BAE +

CNS: Intact

CVS: S1S2 heard

P/A: non tender, non distended

         Liver and spleen non palpable

 

Management:

INVESTIGATIONS:

10/10/21

 

Platelets: 13,000

 

 

11/10/21

 

 

Patient received single donor plasma On 10/10/21

 

 

Diagnosis:

Fever with thrombocytopenia(dengue)