A 38years Female Patient With Viral Pyrexia
THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT
CHEIF COMPLAINTS:-
C/O fever high grade since 5days , increased bleeding during menses since 3days , increased
frequecy of stool since 3days.
HISTORY OF PRESENT ILLNESS
HISTORY OF PAST ILLNESS
No known history of Diabetes,Hypertension, epilepsy, Tuberculosis, Asthma
Known c/o of Hypothyroidism since 10 years
On medication Thyronorm -100mg
PERSONAL HISTORY
Marital status- Married
Occupation- Housewife
Appetite-normal
Diet-nonvegeterian
Bowel-regular
Micturition- normal
No known allergies ,smoking, alcohol
FAMILY HISTORY
No significant family history
GENERAL EXAMINATION
No pallor, cyanosis, icterus, clubbing of fingers, oedema of feet, lymphadenopathy, malnutrition.
Mild dehydration.
VITALS
Temp- 96.5 F
Pr- 86beats / min
Rr- 18/ min
Bp- 110/80 mm /Hg
Spo2-99%
GRBS- 124mg%/dl
SYSTEMIC EXAMINATION
CVS- cardiac sounds-s1s2 normal
- no thrills ,cardiac murmurs
Respiratory system- normal
Abdomen-shape of abdomen- scaphoid
- no Tenderness
- no palpable mass
- Liver, Spleen not palpable
CNS- speech- normal
- concious
PROVISIONAL DIAGNOSIS
Viral pyrexia with Thrombocytopenia
INVESTIGATIONS
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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