General Medicine Blog-9

September 26, 2022

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs.

A 17 year old female, resident of Miriyalaguda, student, came to our hospital with chief complaint of fever.

Date of Admission:-24/09/2022

History of present illness:-
Patient was apparently asymptomatic 7 days back and developed fever which is of high grade, not associated with chills and rigors, fever is continuous and relieved on taking medication and developed generalized weakness and dragging type of pain of both lower limbs since 3 days.

History of past illness:-
Not a known case of diabetes, hypertension, tb, epilepsy.

Personal history:-
Patient has normal eating habit with mixed diet.

Daily routine:-
Patient used to wake up at 6.00AM , goes to college at 9.00AM, takes breakfast at 8.00AM. Then she continues with her studies, takes rice in between 1.00PM-2.00PM, dinner at 9.00PM and goes to bed by 10.00PM.

Family history:-
No significant family history.

General examination:-
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
No Pallor
No Icterus
No Clubbing
No Lymphadenopathy
No Edema of feet
No Malnutrition
No Dehydration

Vitals:-
Temperature-98.6 F
Pulse rate-72 bpm
RR-14 cpm
BP-120/70 mmhg
SPO2-100% at room temperature
RBS-98mg/dl


Investigations:-
HB
PCV
TLC
RBC
PLATELET COUNT
ESR
BLOOD UREA
SERUM CREATININE
SERUM POTASSIUM
SERUM CALCIUM
TOTAL BILURUBIN
SGPT
SGOT
ALKALINE PHOSPHATE
TOTAL PROTEINS
ECG
2D ECHO




Provisional Diagnosis:-
Viral pyrexia with thrombocytopenia

Treatment:-
IV Fluids @ 100ml/hr
Inj. Neomol 1gm ×  SOS
Tab. Pan 40mg × OD
Inj. Zofer 4mg × SOS
Tab. Paracetamol 650mg × TID

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