General medicine case 11
General Medicine Case 11
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A 20 year old male,who works in a sweet shop is a resident of khatanqur came to casualty with chief complaints of fever since 5 days.
History of Present illness:-
Patient was asymptomatic since 5 days ago then he developed high grade fever not associated with chills and rigors which was intermittent and with no diurnal variations. No h/o vomitings,loose stool.No h/o cough,SOB.No h/o burning micturition.No h/o hematuria,melena, bleeding gums, hematemesis and no other bleeding manifestations .
Past History:-
Not a know case of Hypertension, Diabetes, Asthma, tuberculosis, CVD, Epilepsy.
Personal History:-
Sleep is adequate.
Appetite is normal.
Patient takes mixed diet.
Bowel and bladder movements are regular.
No addictions.
Family history:-
No members in family has similar complaints.
Drug history:-
No drug allergy to known drugs.
General examination:-
Patient was conscious, coherent, cooperative,well oriented to place and time.
No anemia, no pallor, no cyanosis, no icterus, no clubbing, no generalised lymphadenopathy.
Vitals:-
Temperature---- 99°F
Respiratory rate--- 18 cpm
Pulse rate--- 98 bpm
Blood pressure---110/90 mm Hg
Systemic Examination:-
RS: Bilateral air entry+;clear
P/A:soft,non tender
CVS:S1S2+
CNS:NFD
Investigations:-
Albumin-trace
Sugar-nil
Pus cells-3-4
Epithelial cells-2-3
RBS-109 Mg/dl
Urea-26 mg/dl
LFT:
T.bil-0.69
D.bil-0.18
AST-50
ALT-19
ALP-128
T.Protein-6.0
Albumin-2.6
A/G-0.76
Sr.creatinine-1.4
Na-138
K-3.8
Cl-98
HCV-negative
Provisional diagnosis:-
Dengue NS1 positive with thrombocytopenia
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