26 YEAR OLD MALE WITH FEVER
November 08 ,22 .
Ultrasound
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 26 yr old male who is a textile supervisor came to causality with c/o...
* Fever since 4 days
* Body pains since 3 days
* Headache since 3 days
History of present illness ;
Patient was apparently asymptomatic 4 days ago then he developed a fever which is low grade with chills and rigor . Then he took the medication (paracetamol ) on his own , had the diurnal variation ( more at night time ) and not associated with any body pains or stomach ache . He came to causality with c/o
* Fever since 4 days
* Body pains since 3 days
* Headache since 3 days
HISTORY OF PAST ILLNESS
N/k/h/o DM , HPT, Epilepsy, asthma
TREATMENT HISTORY
Paracetamol
Dolo - 650
FAMILY HISTORY
Not significant
PERSONAL HISTORY
-Married
Diet - mixed
Appetite - Normal
Bowels - regular
Micturition - Normal
Sleep - inadequate since 4 days
Drug allergy - no known drug allergy
Addictions - occasionally alcoholic
GENERAL EXAMINATION
Patient is consciousness , coherent , cooperative and we'll oriented to time , place and person
Pallor - absent
Cyanosis. - absent
Clubbing. - absent
Icterus - absent
Vitals
Temp - 97.1 F
BP. - 130/100mmHg
PR - 119/min
RR. -20 cpm
SPO2. - 99%
SYSTEMIC EXAMINATION
S1 S2 Sounds heard , no murmurs
Respiratory system
No wheezing
No dyspnea
INVESTIGATIONS
Ultrasound
DIAGNOSIS
Viral pyrexia with thrombocytopenia
TREATMENT
1. IVF@100ml/hr
2. Tab .Dolo 650mg T.I.D
3. Inj .Neomol 1mg IV SOS
IF temp >/= 101°F
4. Inj . PIPTAZ 4.5mg IV /TID
