23 year old female with fever.

Name - A. Rishi koundinya

Batch 2017

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PRESENTING COMPLAINTS:

C/O Fever since 12 days.

C/O Myalgia since 10 days.

C/O Cough since 8 days.

HOPI:

A 23 year female clinically presented with complaints of High grade Intermittent fever associated with chills 12 days ago (on 3rd August). History of productive cough, white scanty sputum since 8 days. She sought for consultation at an local hospital and treated conservatively. Then she had another episode of fever spike after 2 days and underwent rapid dengue investigation on the OPD basis at KIMS, Narketpally which was turned out to be negative. She was started on oral antibiotics and advised to get consultation if fever persists. From 8 th of August she had fever spikes and she sought for consultation and got admitted in a Govt hospital and underwent routine work up in which platelets were found to be 12000. On 10th August her Platelet count was 2000 and had fatigue and weakness; for which she was transfused with 4 RDP on 11th August. On 12th her Platelet count was 45000 which was dropped down to 25000 on 14th August. She was sought for consultation to KIMS, Narketpally i/v/o low platelets. Her platelet count was 10000 before referring her to Kims from Govt hospital. Now she was admitted for further evaluation and management. Upon initial evaluation she had no fever spikes since 3 days. No history of bleeding manifestations and fatigability. 

PAST MEDICAL ILLNESS: 

K/c/o Hypothyroidism.

Surgical History:

S/p - LSCS + Tubectomy 3 months ago.

Personal History:

She was moderately built and nourished.

Sleep adequate.

Appetite normal.

Bowel and bladder are regular.

No addictions.

No allergic history.

Family History:

Her elder son was presented with similar complaints along with rash; and underwent inhospital management and got discharged after recovery.

GENERAL EXAMINATION:

Patient was conscious and coherent.

Afebrile.

Temp 98.6°F; PR : 102bpm; RR: 19cpm; BP: 100/70mmHg; GRBS: 87mg/dl.

CVS: S1,S2+, No added sounds; R/S : BAE+, Clear; P/A : Soft, Non tender, Mild hepatosplenomegaly+; CNS: Intact HMF, NFND.

COURSE IN THE HOSPITAL: 

A 23 year female presented with above mentioned complaints. Upon arrival to casuality, initial examination was done and necessary investigations were sent. Her initial platelet count was 10000 and she was having SOB, Hess test positive. One unit of SDP was transfused on the day of admission which was uneventful. She was advised to take oral fluids to keep her hydrated. Her repeat platelets were 75000. As she wasn't having any fever spike since 4 days before the admission; IV Antipyretic and analgesic medications were de-escalated. By the evening of day 2 of admission her symptoms of SOB has completely resolved. Her platelet were 1.5 lakhs on the day 3 of admission. Her general physical condition was improved and had no fever spikes for a straight 7 days. She was hemodynamically stable and being discharged. 

IN-HOSPITAL TREATMENT:

1. PLENTY OF ORAL FLUIDS.

2. IVF NS/RL @50 ml/hr.

3. INJ. NEOMOL 100ml/IV/SOS ( IF TEMP >101.1°F).

4. INJ. ZOFER 4mg /IV/SOS ( IF NAUSEA/VOMITING).

5. TAB. DOXYCYCLINE 100mg/PO/BD.

TREATMENT AT DISCHARGE:

1. TAB. OROFER XT 1 TABLET DAILY AFTER FOOD AT 2PM.

2. INCLUDE IRON RICH FOOD IN DIET.