65 year old female with viral pyrexia and throbocytopenia

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65 year female,resident of miryalguda ,home maker came to casualty with

C/o-

        > Fever since 1 week

HOPI-

Patient was Apparently asymptomatic 1 week back .

Then she developed high grade fever  ,which was sudden in onset & associated with chills.

She also developed non productive cough.

Sputum - Normal in colour 

No foul smell

No blood in sputum

A day later ,she developed shortness of breath aggregates on walking.(grade 2 -3)

Daily routine:- 

Patient generally wakes up at 6am and takes tea 

At 8 or 8:30 she takes rice as breakfast 

Then she knits mats  for sometime till lunch

and takes rice for lunch and rests for sometime and takes rice again for dinner.

 

She sleeps at 10 pm .

No h/o Loose stools, vomitings,

No h/o Hematuria, dark stools.

No h/o pain abdomen.

PAST HISTORY:-

K/c/o

 

       ~  Diabetes since 20 years

       ~   HTN since 20 years

No k/c/o 

         Tuberculosis 

          Thyphoid

    

          Asthma

  

       

No past history of  allergies or surgeries.

PERSONAL HISTORY:-

diet- mixed

Appetite- normal

Sleep- adequate

Bowel and bladder movement- regular

Micturition - normal

        (No burning sensation)

Addictions:-

Ø  Patient takes alcohol - 90ml 2-3 times a week.

Ø  toddy - 1 full glass ,2-3 times a week 

 Since 15 years 

  no h/o smoking.

FAMILY HISTORY:-

     >No relevent family history.

DRUG HISTORY:-

Patient takes tablets for diabetes 

Atorvastatin 100mg

Glimipide 

Metformin 

GENERAL EXAMINATION:-

I have taken the consent of patient and examined 

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

Moderately built & moderately nourished.

No pallor,

No Icterus,

No cyanosis,

No Generalised  lymphadenopathy,

No clubbing,

No Bilateral pedal edema 

Clinical pictures :—

Vitals:-

 §   Temperature - Afebrile 

 §   BP -110/70mmhg

 §  PR - 75 bpm

 §   RR -18cpm

 

SYSTEMIC EXAMINATION:-

CVS -

        S1 S2 heard

        No thrills

  

        No murmurs

      

RESPIRATORY  SYSTEM-

ON INSPECTION:-

Chest appears  bilaterally symmetrical .

Respiratory movements appear equal on both sides.

Position of trachea - central

No scars 

ON PALPATION:-

All inspiratory findings are confirmed 

Position of Trachea - central 

No drooping of shoulders

Apical impulse in left 5th inter coastal space ,2cm medial to mid clavicular line.

Vocal fremitus- felt on supra and infra scapular area

           

ON PERCUSSION -

                               Right           Left

Supra clavicular-       R                 R

Infra clavicular-         R                  R

Mammary.        -        Dull.           Dull

Suprascapular-          R                  R

Interscapular-            R                  R

Infrascapular-            R                  R

ON ASCULTATION:-

                                   Right            Left

Supra clavicular-     NVBS            NVBS

Infra clavicular-       NVBS            NVBS

suprascapular-        NVBS            NVBS

ABDOMEN-

     No scars

    Shape of abdomen – obese

 

     No Tenderness

CNS-

 

   Patient is conscious ,

 

   Speech is normal,

 

   Memory is intact.

PROVISIONAL DIAGNOSIS-

Viral pyrexia

Thrombocytopenia 

INVESTIGATIONS:-

17/01/23

Treatment;-

I.V fluids - NS 75 ml / hr

Tab dolo 650mg