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)
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