19/M with fever and body pain

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Cheif Complaints :

A 19yr old male patient came to the opd with chief complaints of fever Since 1 week.

HOPI:-

Patient was Apparently asymptomatic 1 week back then he developed fever with chills which is high grade ,sudden in onset & associated with body pains .Relieved on medication.

2 days back he was taken to outside hospital there his platelet count was 1,29,000 cells/cumm, yesterday they were 1,32,000cells/cumm.Today they were 98,000cells/ cumm.

No h/o Loose stools, vomitings,

No h/o Hematuria, dark stools.

No h/o pain abdomen,giddiness.

PAST HISTORY:-

Not a k/c/o HTN,DM, Thyroid, Epilepsy.

PERSONAL HISTORY:-

diet- mixed

Appetite- normal

Sleep- adequate

Bowel and bladder movement- normal

GENERAL EXAMINATION:-

Patient was conscious, coherent, cooperative,well oriented to time place and person.

Moderately built & moderately nourished.

No pallor,Icterus,cyanosis, lymphadenopathy, clubbing.

BP -90/60mmhg

PR -84

RR -14cpm

Spo2 -99

Temp:-99.5 F

CVS- S1 S2 +

CNS- NAD

R/S - BAE +

P/A - soft,nontender .

PROVISIONAL DIAGNOSIS:-

DENGUE( NS1 +, IgM+) WITH THROMBOCYTOPENIA.

TREATMENT:-

1) Iv fluids NS @ 100ml/hr

2) Tab DOLO 650 mg Po/TID

3) INJ PAN 40 mg IV/OD

4) INJ NEOMOL IV/ SOS( IF TEMP >101 F

5) INJ ZOFER 4mg IV/SOS

6) BP AND TEMP MONITERING