A 55 years old male patient with complaints of Fever and headache

A 55 yr old male patient came to opd with chief complaints of fever and headache since 5days.

HISTORY OF PRESENT ILLNESSES

patient was apparently asymptomatic 8 days back,then he developed low grade fever which is intermittent and is not associated with chills and rigors. Fever relieves on medication.

Headache is in frontal region and is not associated with vomitings ,giddiness and blurring of vision.
No history of melena or hematuria

PAST HISTORY

 No H/O dm,htn,thyroid,asthma,epilepsy.  
FAMILY HISTORY
No significant family history

Treatment history:— none
PERSONAL HISTORY:

Married

Diet-mixed

Appetite:- decreased 

Sleep:- not adequate

Bowel and bladder movements- normal

Addictions:— alcohol consumption everyday.


GENERAL EXAMINATION
patient is concious, coherent and cooperative.

                Vitals:— Temp:- 98 F

                Rr:- 20/min

                Pr:-64/min

                Bp:—supine - 100/70mmhg

                   
     
Pallor_ absent
Icterus absent
Cynosis absent
Clubbing absent
Lymphadenopathy absent
Oedema absent
SYSTEMIC EXAMINATION

CVS:— S1 and S2 heard no murmers

Rs:- BAE- normal

CNS:— NAD
PA :— soft and nontender.
investingations;

Serology: NS1 positive


COMPLETE URINE EXAMINATION

Colour pale yellow
Albumin +++
Pus cells 4 - 5
Epithelial cells 2- 4

RBS : 114

MP - ve

Mp strip -be

RFT: -
Urea : 35 mg/DL
Creatinine : 1.2
Uric acid : 6.1
Ca+2 : 9.9
Phosphorus : 3.5
Na+ : 138
K+ : 3.7
Cl- : 98

LFT
TB : 0.73
DB : #0.26
SGOT :#102
SGPT:#50
ALP:#234
TP:6.4
ALB : 3.7
A/G ratio : 1.35
Hemogram _

ECG
 DIAGNOSIS
Viral pyrexia with thrombocytopenia
With NS1 postive

TREATMENT
1) IVF ns , RL at 125ml/min
2) INI ZOFER 4mg IV sos
3) temp monitoring every hourly
4) Bp monitoring every 4th hourly
5) w/f bleeding manifestation
6) strict i/o charting
7) GRBS monitoring 6th hrly

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