a case of 15 year old boy with viral pyrexia with thrombocytopenia

15 year old boy,resident of Ap lingotam studying 10th standard..
Patient was healthy before and regular to school, apparently symptomatic from 4 days.
 
Patient had chief complaints of fever 4 days  which is high grade,intermittent, associated  with chills and rigors,more in the nights; releived on medication, no complaints of cold, cough.

Complaints of abdominal pain since friday( right upper quadrant, epigastric right lumbar and right hypochondriac) associated with vomitings from 4days..(5episodes on day 1 ,3episodes on day 2 ,1episode on day 3)non projectile,non bilious,contents only food particles,not blood tinged.

Stools normal quantity,color,consistency but increased frequency,no mucus or blood stained,no foul smell.
Generalised weakness present 

Headache present B/L frontal and temporal areas,no photophobia or phonophobia,relived on medication,dizziness associated with head ache.

 History of present illness: Complaints of 4 episodes of loose stools yesterday 

No c/o constipation, malena, blood in stools
 No Burning micturition, high colored urine present 

History of past illness: not a k/c/o DM, HTN, epilepsy, aasthma,TB.
No significant weight loss history

Personal history: 
Diet : mixed
Appetite: normal
Bowels: regular 
Bladder- normal micturition

Family history:
No history of DM, HTN CAD, CVA, aasthma   in the family

General examination: patient is conscious, coherent, cooperative 
Pallor is seen.
No icterus, cyanosis, clubbing,lymphadenopathy, edema

Vitals:
Temperature: 98.9F
Pulse: 80bpm
Respiratory rate: 19/ min
Bp: 110/60mm hg
Spo2: 98% at RA
GRBS: 87 mg%

Systemic examination: 
Cvs: S1 S2 heard no additional sounds or murmurs
Rs: NVBS
Abdomen: soft,non tender,no hepatomegaly
No splenomegaly
Cns: higher mental functions intact 

Provisional diagnosis: fever with thrombocytopenia 
Dengue- Ns reactive





TREATMENT 
INJ .NEOMOL IV/SOS IF TEMP >101⁰F
TAB PARACETAMOL 650 MG PO/TID
INJ .PANTOP 40MG IV/OD
TEPIDSPONGING/SOS 
IVF -NS @ 75ML/HR (20 MACRDOPS/MIN).
BP,PR,RR,SPO2,MONITORING
TEMP CHARTING
INPUT OUTPUT CHARTING
PLENTY OF ORAL FLUIDS
WATCH FOR BLEEDING MANIFESTATIONS
INFORM SOS


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