52 year old female with fever,cough and cold since 5 days

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CHIEF COMPLAINTS:

C/o fever  cough and cold since 6 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 6 days ago then developed fever which is insidious in onset,gradually progressive ,associated with rigors and chills.

Cough since 6 days associated with expectoration which is greenish yellow in colour

Cold since 6 days 

No h/0 nausea ,vomiting,bodypains 

No rashes on body

H/O fever 45 days ago relieved on medication

No H/O burning micturition 

 relieved with medication .

- No c/o Vomitings , blood in urine output /burning micturition/ cough/cold /Loose stool.

No c/o PainAbdomen/Or any bleeding manifestations

i.e., No hematuria/ Melena or blood

in stool/Bleading gums

Petechiae /rash.

No SOB/chest pain/palpitations

3. HISTORY OF PAST ILLNESS

Underwent hysterectomy 25 years ago

K/clo hypothyroidism since 2 years (on regular medication)

(Increased weight)

No  Similar complaints in the past

Not a K/clo DM, HTM, Asthma, TB, Epilepy, CVA, CAD.

Allergic history:- No history of any kind of allergies for food/drugs

Personal history:

Occupation:labour worker

Appetite:normal

Bowel and bladder :normal

Diet:mixed

Sleep:adequate

Addictions:toddy since 30 years

Occasionally

Family history:- no significant family history 

General examination:

NO PALLOR

NO CLUBBING

NO EDEMA

No cyanosis,clubbing,lymphadenopathy,

Edema,pallor

Pt is c/c/c

Temperature :98.0f

Pr:86bpm

Rr:22 cpm

Systemic examination:

Cvs :s1 and s2 +

Rs :BAE+ ,crepts in left subscapular region +

P/A: soft ,nontender,no organomegaly

CNS:No focal neurological deficits

 

 PROVISIONAL DIAGNOSIS:- 

? Viral hemorrhagic fever 

? Dengue 

INVESTIGATIONS:- 

DATE :- 1/2/24

NS 1 POSITIVE 

RBS - 244 mg/dl

Blood group:- B +ve

BT - 2min 30 sec

CT - 5 min 00 sec

PT  16 sec

INR -   1.11

Aptt - 32 sec

CBP:- 

Hb:- 14.5gm/dl

TLC :- 13,200cells N-70/L-15/E-00/M-15/B-0

PLT - 13000 lakhs /cumm

CUE:- 

Alb- Trace

Sugars - nil

Pus cells - 2-4cells

epi:- 2-3cells

LFT:- 

Total bilirubin -1.09    mg/dl 

Direct - 0.24mg/dl

SCOT (AST):- 267 IU/L 

SGPT [ALT] - 224 IU/L

ALKALINE PHOSPHATE:- 316 IU/L

TOTAL PROTEINS:- 6.8gm/dl

RFT:- 

Serum creatinine:-0.8    mg/dl

Serum Na :- 141   mEq/L

Serum K :- 49    mEq/L

Serum cl :- 98 mEq/l

Blood urea - 24mg/dl

DIAGNOSIS :- 

DENGUE WITH THROMBOCYTOPENIA

( NS1 POSITIVE ) 

TREATMENT :- 

IVF NS @ 75ml /hr

INJ NEOMOL IV/SOS IF TEMP GREATER THAN 102 

TAB DOLO 650 mg PO/BD 

WATCH FOR ANY BLEEDING

MANIFESTATIONS

TEMERATURE MONITORING

EVERY 4tu hourly

MONITOR VITALS 

INFORM SOS