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

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