15yr old with fever and thrombocytopenia

 CASE SCENARIO:

     A 15 yr old male came to opd on 03/08/2021 with chief complaints of fever, pain abdomen since 5 days and vomiting since 2 days.

History of present illness:-

Patient was apparently asymptomatic 5 days back. Then he developed high grade fever which was intermittent in nature associated with generalised body pains, chills but not associated with rigors or rashes. H/o diffuse pain abdomen present since 5 days. H/o vomitings present with food as content, non bilious, non projectile. H/o foul smelling black stools present since 4 days. 

*No h/o cough or cold

*No h/o diarrhoea/constipation

*No h/o burning micturition but urine is high coloured.

*No h/o bleeding manifestation

*he got tested outside the hospital for Dengue NS1- positive 

*Thrombocytopenia - Platelet count - 41,000 (tested outside the hospital)

*Widal test 1:80 positive

Patient was referred to our hospital I/V/O low platelet count

History of past illness:-

*Similar complaint in past but relieved spontaneously (5 years back) (obstruction?)

*Not a k/c/o DM/asthma/epilepsy/CAD/TB

Personal history:

Diet: mixed

Appetite : normal

Bowel: regular

Micturition: normal

Family history: not significant

GENERAL EXAMINATIONS:-

Patient is conscious, coherent and cooperative

*No-Pallor/Icterus/Cyanosis/Clubbing/Lymphadenopathy/Edema/Malnutrition

*Temperature -99 F

*Pulse rate - 96 /min

*Bp - 110/70 mmhg

*Spo2 - 99 %

*GRBS - 126 mg%

SYSTEMIC EXAMINATION:-

Cvs :S1S2 heard, no murmurs

RS:BAE+, NVBS+

P/a : abdomen is flat, non distended, diffuse tenderness+, guarding and rigidity +

Bowel sounds- present

Hernial Orifices - Normal

Liver Spleen - Not palpable

Genitals speculum examination, PV examination, P/R examination - Normal

CNS:NFND

Investigation ordered :-

*Complete urine examination

*Liver function test

*Blood grouping and typing

*Serum creatinine

*Serum urea

*Serum electrolytes 

*Chest x ray

*Ecg            

Investigation:-

MEDICATIONS AND REPORTS:

ON 03/08/2021

ON 04/08/2021

ON 05/08/2021:

VIEWS:

Improvement in platelet count.

Improvement and  recovery is seen in this patient.

Provisional diagnosis:

VIRAL PYREXIA THROMBOCYTOPENIA

 DENGUE

* It says there’s fluid around the spleen, liver and kidney.

* Gall bladder wall is swollen.

*He has fever and thrombocytopenia which are classical symptoms and signs of dengue

* Abdomen pain  can also occur in dengue.

*Body pains 

*The platelets were 32,000 when he got admitted.