30 year old with fever and Thrombocytopenia
Unit 3:
Interns:
Dr .Leela
Dr Harsha
Dr Archana
Dr Kalyan
Dr Jeehariki
Dr Raveen PGY1
Dr Aashitha PGY2
Dr Aravind PGY3
Dr Vamshi PGY3
Dr Hareen SR
Dr Praveen Naik Ass Prof
DR. RAKESH BISWAS HOD
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Here is a case i have seen today 10/2/2021
30 year old female came to the casualty at 7pm with Complaints of
- Fever since 3 days
Associated with chills
-Generalized weakness +
-Myalgia +
-Headache +
-1 episode of bleeding from nose in the morning.
- 2 episodes of dark colored stool in the morning
Patient was apparently asymptomatic 3 days back after which she developed fever which was insidious in onset and the fever was more early in the morning and late at night. She says her fever was also associated with body pains and headache, around the occiput region, on and off.
H/o bleeding manifestation from nose in the morning.
She also tells she had had 2 episodes of dark stools since morning
Patient works as a farmer at a local village and got married to a farmer 13 years back. She has 3 kids, all of them got delivered via normal vaginal deliver.
She had tubectomy done 6 years back.
GENERAL EXAMINATION
Patient is thin built.
She has no pallor,cyanosis,clubbing, edema, lymphadenopathy
VITALS:
PR - 72 bpm
BP - 110/70mmhg
RR - 18 cpm
SPO2 - 98%
Temp - 100 F
SYSTEMIC EXAMINATION:
CVS - S1,S2 +
Lungs - clear on auscultation
Per Abdomen - Non tender
Bowel sounds +
ECG:
CHEST X RAY:
USG REPORT:
10/2/2021
Hb:11.7 mg/dL
PCV:35.2 %
TLC:6,300 Cells/cubic mm.
Platelets: 2000cells/ cubic mm.
ONE UNIT OF SDP transfusion was done.
11/2/2021.
Hb:9 mg/dl
PCV:27.2%
TLC:5,800 cells/ cubic mm
PLATELETS:10,000 cells
1. Patient advised to take plenty of oral fluids
2. IV Fluids
3. Tab Dolo 650mg SOS
4. Temperature charting
Tepid sponging
5. Monitor vitals
DIAGNOSIS:
Fever with Thrombocytopenia.
