GM Case 04

 

General Medicine case-4

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A 32years old Male who work as construction worker presented to the OPD with Chief complaints of fever since 4-5 days,cold since 1 week, cough since 1 week,headache and giddiness since 1 week.

History of present illness:-

Patient was apparently asymptomatic since 1 week ago. Then he gradually developed weakness and low grade intermittent fever with no diurnal variation associated with non productive cough and cold. 

Patient daily routine is he wakes at 5 A.M in morning. Has his breakfast by 8 A.M and goes to work by 9 A.M and has lunch by 2 P.M . He does his routine work and have dinner by 8 P.M and sleep at 10 P.M

Past History:- 

No history of hypertension, diabetes mellitus , tuberculosis, asthma, and epilepsy. 

No history of any surgery. 

Personal History:-

Patient takes mixed diet.

Sleep is adequate.

Appetite is normal.

Bowel and Bladder movements are regular.

Consume alcohol occassionally.

No history of smoking.

Family history :-

There is no history of similar complaints in the family members.

General examination:-

- Patient is conscious, coherent and cooperative.

- He is well oriented to time , place and person . 

- No anemia, no pallor, no cyanosis, no clubbing of fingers,no generalised lymphadenopathy.

Vitals:-

Temperature:- 98.6F 

Blood pressure :-  110/70 mmHg 

Pulse rate: - 62bpm

Respiratory rate :- 20 cycles/min.

  

Systemic Examination:-

Cardiovascular system:- 

Inspection:-

Chest wall is bilaterally symmetrical

No Precordial bulge

No visible pulsations, engorged veins,scars, sinuses

Palpation:

JVP - normal

In midclavicular line 

Ausculation:

S1 ,S2 Heard

RESPIRATORY SYSTEM

Bilateral airway +

Position of trachea- central

Normal vesicular breath sounds - heard

No added sounds

PER ABDOMEN

Abdomen is soft and non tender 

Bowel sounds heard

Free fluid grade 1 ascites 

CENTRAL NERVOUS SYSTEM

Patient is conscious 

Reflexes are normal 

Speech is normal .

Investigations:-

Final diagnosis:-  

Dengue fever with Thrombocytopenia

Treatment:-

IVF NS , RL @ 125 ml/hr 

-INJ PANTOP 40 MG /IV/OD 

-INJ ZOFER 4 MG /IV/SOS 

-TAB DOLO 650 /PO/ SOS

-INJ NEOMOL 100 ML IV / IF TEMP > 101 F 

-SYRUP GRILLINCTUS 10 ML PO/OD /TID WITH 1 GLASS OF WATER 

-TEMP CHARTING 4 TH HRLY , TEPID SPONGING 

-MONITER VITALS 

-POSTURAL BP MONITERING 4 TH HRLY 

-PLENTY OF ORAL FLUIDS .

At which stage the platelet transfusion should be done????