Case history 3
A 30 years old male for brought to casualty with complaint of fever for 3 days and chills.
HISTORY OF PRESENT ILLNESS :
Patient complaints of abdominal pain and epigastric pain
Patient complaints of low grade and continuous type of fever associated with chills and headache .
Patient is not associated with vomiting and loose stools.
Patient visited a RMP and received an injection for fever that caused subsided fever temporary.Patient complaints of fever again in the evening along with chills. So patient admitted in the local hospital and on investigation in local hospital he was identified with low platelet count and given fluids but still his platelet count was decreased to 14,000.
PAST MEDICAL HISTORY:
Patient complaints of covid -19 postive one year back and was admitted in the hospital for fever, cough, shortness of breath for which HRCT was done ( High resolution computer tomography).
He was managed with D2 remdesvir injection and 6 doses were given .
Patient complaints of increase in blood glucose levels duration that time but not recieved any medication.
No history of diabetes, hypertension, CAD , asthma, tuberculosis .
No history of any surgeries ,any chemo/ radiation ,blood transfusion .
PERSONAL HISTORY:
Diet :mixed.
Appetite : decreased
Bowel movement : normal.
Micturition: normal.
Addictions :
Alchols: patient drinks 2 pegs of whiskey occassionally since 4 years and no other addictions like smoking , drugs .
FAMILY HISTORY :
No history of diabetes, hypertension , heart diseases, cancer, tuberculosis and asthma in the family.
No history of any hereditary disease .
GENERAL PHYSICAL EXAMINATION:
Patient consent was taken and examined in well lit room.
Patiently was coherent , cooperative and conscious.
No pedal oedema.
No generalised lymphadenopathy.
No clubbing and cyanosis .
VITALS:
Blood pressure :-
In supine position: 90/60mmHg.
In standing position : 110/20 mmHg.
Pulse rate : 60bpm.
Temperature : increased.
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills and cardiac mummers .
S1 and S2 are heard .
Respiratory system:
No wheezing and dyspnoea.
Postioning of trachea is central and breath sounds are vascular.
Abdomen:
Shape of abdomen: scaphoid .
No tenderness and no palpable mass is present.
No free fluid and bruits and liver and spleen are not palpable and bowel sounds are not heard .
Central nervous system:
Patient is conscious and speech is normal.No signs of meningeal irritation such as neck stiffness and kerning's sign.
Cerebral signs such as finger - nose in coordination and knee - heal incoordination are not present .
PROVISIONAL DIAGNOSIS:
Viral pyuria and thrombocytopenia .( Dengue and NS1 antigen)
INVESTIGATION:
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Blood sugar fasting |
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