A18 year y female, fever with thrombocytopenia

Unit 1 admission 

Ward case 


Dr K VAISHNAVI PGY3 
DR NIKITHA PGY3 
DR RAVEEN PGY2
A 18  year old female , student  presented to the casuality with 
C/O fever with chills since 10  days 
H/o nausea present 
No H/O bleeding manifestions 

Pt was apparently asymptomatic 10 days back ,later she developed high grade continuous type of fever subsided on medication associated with chills and  aggravated since 4 days 
 History of cold present 10 days back  subsided on taking medication,diurnal variation absent 

History of cough with mild scanty sputum ,mucoid in constistency
Not associated with giddiness 
Head ache +,myalgia + 


Past history : 
Not a K/C/O DM,HTN,Asthma ,TB,epilepsy 
No similar complaints in the past 

Personal history : 
Diet - mixed 
Appetite - decreased 
Sleep - adequate 
Bowel movements : regular 
Bladder movements : regular 
No history of smoking or alcohol consumption 


O/E:
Pt is conscious,coherent and cooperative 

Vitals: 
Afebrile to touch
BP: 110/70
PR: 82  bpm
RR: 16
Spo2: 99% on room air

CVS: S1,S2 heard 
RS: BAE +,NVBS 

P/A: soft , non tender 
 Bowel sounds heard
CNS: normal
 Provisional diagnosis : Fever with thrombocytopenia 

Investigations : 
ECG report:

Usg report: Gall bladder wall edema with mild ascites.

Chest X-ray report:
HEMOGRAM : 
Hb - 13.4 
TLC - 4000
N - 73
L - 18
M - 08
E - 01
B -00
Pcv - 37.8 
RBC - 4.50
Plt - 1.2


CUE : 
Pale yellow 
Albumin - nil
Sugar -nil 
Pus cells- 2 to 3 
Epithelial cells - 2 to 3 


RFT  : 
Creatinine - 0.7
Urea - 15

LFT : 
TB - 0.72
Db - 0.20
AST - 23
ALT - 75 
ALP - 200
TP - 5.4
ALB - 3.5
A/G - 1.81

Treatment:

IVF: Ns,RL,DNS@100ml/hr
Inj.pan 40mg/iv/od
Inj.zofer 4mg/iv/sos
T.pcm 650mg/po/sos
Sup.mucaine gel /po/tid

Comments

Post a Comment

Popular posts from this blog

A55year old male with ? Nephrotic syndrome Known case of Hypertension since 10 daysAnemia under evaluation.

Image
This is Online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent .Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.  CASE DISCUSSION:  •55 year old man, owns a restaurant at choutuppal presented with the complaints of Bilateral lower limb swelling since 1 month Reduced urine out since 20 days Abdominal distension since 7 days Scrotal swelling since 4 days Patient used to previously work as a farmer  and later in 2004 he and his wife started running their own restaurant at Choutuppal. He is a father of 2 children.   22 years back:  He got diagnosed with pulmonary kochas for which he used ATT for 6 months   1 month back :  He first developed left lower limb swelling extending upto his ankle and he later gradually developed swelling of h
Read more

A 50 year old male with acute Gastroenteritis

UNIT 4 ADMISSION:- A 50 year old male came to casuality with complaints of Vomiting since 2 hours Loose stools since 2 hours HOPI: Pt was apparently asymptomatic 2 hours back then he had vomitings 4-5 episodes, nonbilious in nature,non projectile, food particles as content and h/o loose stools since 2 hours,watery in consistency,  No h/o fever,cold,cough, burning micturition  No h/o pain abdomen Past history: No similar complaints in the past He is a a k/c/o HTN since 3 years and on Tab.telma 20 mg Po/od and  Depression and on tab.sizdon 25mg Po/od Not a k/c/o DM type 2/ASTHMA/EPILEPSY/TB He is a non alcoholic and non smoker O/E:  Pt is conscious , oriented to time , place , person   No pallor , Icterus, cyanosis , clubbing, lymphadenopathy , edema.  Vitals:  Temp - 98.7 BP - 90/60mm of hg PR - 112 bpm  Spo2 - 96%at RA  RR- 18cpm GRBS - 149 mg/dl  Systemic examination:  Cvs: s1 s2 present , no murmurs Rs: BAE present, normal vesicular breath sounds present.  P/A: soft, non tender 
Read more

50 year old male with chronic pancreatitis with mild ascites.

Image
Chief complaints:- A 50 year old male came, working as a daily wage labourer from Nagonda presented  to the casualty yesterday with the complaints of  Pain abdomen since 1 week. Hopi:-  Patient consumes around 90ml of whiskey everyday since the past 10 years and he also smokes 1 pack of cigarettes per day.  He was apparently alright 7 years back then he developed pain abdomen around umbilical region which was non radiating and dull aching in nature, present throughout the day and wasn't relieved on sitting or bending forward. He went to a local hospital when in he was admitted for 4 days and continued to consume the prescribed medications for 1 week post admission. He thereafter stopped consuming alcohol for 7 months post admission. He later continued consuming alcohol. 1 month later he developed a similar episode of pain abdomen for which he used the medications prescribed as per his previous hospital admission. 4 years back - He experienced pain abdomen for which he consulted a d
Read more