50 year old female with fever ,thrombocytopenia

​This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.


CASE PRESENTATION:


A 50 year old female came to casualty  with c/o

Fever since 7 days 


HOPI:

Patient was apparently asymptomatic 7 days back then she developed fever which is  of high grade,intermittent, not  associated with chills and increased during night.2 days later She went to a local hospital where she was diagnosed with typhoid.she was on medication. Her platelets count reduced and fever is not subsided. 

She also complained of mild head ache since 4 days ,relieved on medication 

No h/o nausea, vomiting 

No h/o loose stools/constipation 

No h/o pain abdomen

No h/o Burning micturition 


PAST HISTORY:

Not a K/C/O DM/HTN/ASTHMA/EPILEPSY/CAD/CVA


Personal History :

Diet : mixed
Appetite : Normal 
Sleep : Adequate 
Bowel movements : Regular 
Bladder movements : Regular 

On Examination :

Patient is conscious, coherent and cooperative.
Pallor -Absent
Icterus -Absent
Cyanosis -Absent
Clubbing -Absent
Lymphadenopathy -Absent
Edema -Absent















VITALS :

AT THE TIME OF ADMISSION :
TEMP. : 98.6
PR : 88 BPM
RR : 16 CPM
BP : 100/60 MM HG
SpO2 (on Room air) : 98%
GRBS:108 GM/DL


On Systemic Examination:

CVS : S1, S2 heard
RS : BAE present 
P/A : soft, Non tender

CNS : HMF Intact


INVESTIGATIONS 













PROVISIONAL DIAGNOSIS:VIRAL PYREXIA  WITH THROMBOCYTOPENIA 


TREATMENT:

1.IV FLUIDS NS@70 ML /HR

2.TAB.PCM 650 MG/PO/TID 

3.INJ.PAN  40 MG/IVBD

4.INJ.ZOFER 4MG/IV/SOS

5.INJ.NEOMOL 1GM/IV/SOS

6.VITALS MONITORING 


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