A 30 yr male with viral pyrexia and thrombocytopenia

A 30 year old male patient who is farmer by occupation and a resident of kattaguru mandal, kurumarthy.

CHIEF COMPLAINTS -

Patient complained of fever body and neck pains since 3 days, dark coloured stools since 2 days and dark yellow coloured urine since 2 days.

HISTORY OF PRESENT ILLNESS -

Patient was apparently asymptomatic 3 days back then he developed 3 episodes of high grade fever associated with chills and not associated with cough. Patient also developed loose stools in the past 2 days and an episode of vomiting which was nonbilious, non projectile and contained food particles. He was taken to a nearby private hospital, where he was diagnosed with dengue and he was advised to get admitted in that hospital. But the family members chose to admit him in our hospital and they did so on 3 December 2021.

 

PAST HISTORY -

Not a known case hypertension/diabetes/thyroid /tuberculosis/epilepsy/asthma

FAMILY HISTORY -

No relevant family history

No known cases of diabetes/hypertension/ tuberculosis/asthma/epilepsy/thyroid

PERSONAL HISTORY -

Appetite is decreased

Mixed diet 

Sleep is not adequate 

Bowel and bladder movements are irregular

Associated with BURNING MICTURATION

No known allergies

Patient consumes alcohol occasionally.

PHYSICAL EXAMINATION -

GENERAL -

Patient is conscious ,coherent and cooperative 

Patient is well oriented to time and place

Moderately built and moderately nourished

Pallor:absent

Icterus: absent

Clubbing:absent

Cyanosis:absent

Lymphadenopathy: absent

Edema: absent

VITALS -

Temperature: afebrile

Pulse: 78 bpm

Respiratory rate: 16 per min

Blood pressure: 80/60

SpO2 at room air: 98%

SYSTEMIC EXAMINATION -

Cardiovascular system -

s1 and s2 heard ,no murmurs 

Respiratory system -

Central position of trachea 

Vesicular breath sounds

No wheeze,no dyspnea

Abdomen -

Bowel sounds present

Normal shape 

No tenderness

No palpable masses

PROVISIONAL DIAGNOSIS -

Viral pyrexia with thrombocytopenia

INVESTIGATIONS -

Hemogram - 

Serum electrolytes -

ECG -

Blood urea -

Ultrasound -

 TREATMENT -