25 yr old female patient

 

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25 yr old female patient resident of miryalguda,housewife by occupation came to OPD with chief complaints of fever since 5 days and giddiness since 5 days.

History of presenting illness:

Patient was apparently asymptomatic 5 days back the she developed fever  which is sudden in onset, continuous ,high grade fever, associated with chills and rigors relieved on medication .

Fever is associated with headache,retro orbital pain.

History of generalized weakness, body pains.

History of nausea and vomitings(non bilious) 3 to 4 times a day projectile

History of cough (non productive)

History of abdominal pain, burning micturition .

Past history:

 no similar complaints in the past

Not a know case of diabetes, hypertension,asthma ,Tb, cardiovascular disease , seizures, thyroid problems.

Treatment history: 

Undergone blood transfusion during cesarean section due to heavy blood loss

Surgical history:

Undergone 3 cesarean sections

Personal history:

Diet-mixed

 Appetite-normal 

Bowel -regular

Burning micturition

No addictions

No allergis to food drugs

Family history: not significant

Menstrual history: 

Age of menarche 13yrs

Cycles regular

Normal flow

Physical examination: 

Patient is conscious coherent co operative and well oriented to time place person

Moderately built 

Moderately nourished

No history of pallor ,cyanosis , clubbing,lympedenopathy,pedal edema

Vitals :

Bp:90/60mm hg 

RR:20cpm

Pulse rate:78bpm

Temp:99.5c

Systemic examination:

CVS

S1 n S2 heard 

No murmurs

Respiratory system:

Trachea central 

Bilateral air entry present 

Vesicular breath sounds heard

No wheeze or other adventitious sounds

Per abdomen examination

Shape of abdomen : scaphoid

Umbilicous Central no scars sinuses visible pulsations engorged veins

No local rise of temperature

Tenderness present

No palpable mass 

No oragnimegaly

Bowels sounds present

CNS examination 

Conscious, gait normal

Normal speech 

No meningial signs like neck stiffness

Reflexs:    biceps   triceps supinator knee ankle 

Rgt.        All are present

Lft.

Investigations

Provisional diagnosis: viral pyrexia with thrombocytopenia

Treatment:

Iv fluids -DNS

Ringer lactate 

Inj.pan 40 mg iv/of

Inj.zofer 4mg iv /tid

Monitoring vitals