A23 year old female with fever ,cough,myalgia since 12 days

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A 23 year old female resident of Miryalguda home maker by occupation came with chief complaints of fever since 11 days.

HOPI :

Patient was apparently asymptomatic 12 days back.

Then she developed fever for 7 days which was high grade intermittent and associated with chills and rigor

She went to a local hospital and took medication and the fever subsided.

Then after 3 days she again had fever for which she came our hospital and widal test was done and it was negative .

She tested at local hospital and it was positive for dengue and they visited a hospital in Nalgonda and was told her platelet count was low and then they went to Osmania hospital because of some they came our hospital on 14/08/2022

PAST HISTORY:

No similar complaints in the past

Not a known case of Diabetes Hypertension Asthma TB Epilepsy

History of hypothyroidism during third pregnancy and it was normal after delivery

History of Tubectomy and LSCS 3 months back 

FAMILY HISTORY :No significant family history

PERSONAL HISTORY:

Diet mixed

Appetite Normal

Sleep adequate 

Bowel and bladder movements regular

Addictions :No addictions

DRUG HISTORY: No history of allergy to any kind of drugs

 GENERAL EXAMINATION:

Patient was conscious coherent and cooperative

Moderately built and nourished 

pallor present

No, Icterus, Cyanosis, Clubbing, generalized lymphadenopathy

 bilateral pedaledema 

Vitals

Temperature 

RR 20 cpm

PR 90

BP 110/90

GRBS  106gm/dl

Systemic Examination

RESPIRATORY SYSTEM EXAMINATION 

Inspection:

Symmetrical chest 

No scars and sinuses 

Trachea central

Palpation:

Inspectory findings are confirmed

Percussion: 

Resonant note present in all lung areas

Ascultation:

Breath sounds heard. 

PER ABDOMEN 

Inspection: 

No Abdominal distension 

No scars, sinuses, mass visible

Palpation:

Inspectory findings are confirmed 

No local rise of temperature

Tenderness absent

Mild hepatomegaly and mild spleenomegaly

Auscultation

Normal bowel sounds heard

No bruit heard

CARDIOVASCULAR SYSTEM EXAMINATION 

Inspection : Bilaterally symmetrical chest present 

No scars, sinuses

Palpation

Inspectory findings are confirmed

Apex beat normal

On Auscultation : 

S1 S2 heard

No murmurs or additional heart sounds

CENTRAL NERVOUS SYSTEM EXAMINATION 

Higher mental functions intact

Cranial nerves intact 

No focal neurological defecits

INVESTIGATIONS:

DIAGNOSIS 

Dengue fever 

TREATMENT 

Tab Doxy 100 mg PO BD 

Tab DOLO 650 mg PO SOS 

PCM 1 gm IV SOS 

OPTINEURON 1 Ampoule IV OD 

Inj Zofer 

IV Normal saline and Ringer lactate 75ml/hr