Gm case

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.


Chief complaint:-
A 26 years old female presented with the chief complaints of 
- fever
- heavy menstrual bleeding

History of presenting illness:-
Patient was apparently  asymptomatic 5 days back then she developed fever which of is low grade not associated with chills and rigor , relieved on medication.2 days back she had her menstrual bleeding which is high for which he went to hospital and was given medication. When she went for follow up check up it is found that her platelet count is low and dengueNS1 is reactive.

History of past illness:-
 N/K/c/o :-Diabetes mellitus , hypertension,TB,asthma


Personal history:-
Diet:-mixed
Appetite:- normal
Bowel:- regular
Micturation:-normal
Addiction:-  no addictions 

Menstrual history:
Age of menarche: 12 years
-28 day cycle with 3 day menstrual bleed
-LMP: 1/9/22 

General examination:-
The patient is c/c/c and well oriented with time and place.

Vitals:-
Pulse rate:-  86 beats/min
Respiratory rate:-  14/min
Bp:- 110/70mmhg
Temperature:- 99 F


Physical examination:-
Pallor:-absent
Icterus:-absent
Cyanosis:-absent
Clubbing:-absent
Generalized lymphadenopathy:-absent
Oedema:-  no oedema 
Koilonychia :- not present

Systemic examination:-

Cvs
S1 s2 are heard with no murmers

Rs
BAE :- present
Vesicular breath sound are heard


Cns
Level of Conciousness : concious
Speech : normal
provisional diagnosis:-
Dengue with thrombocytopenia
Treatment:-
Iv fluid
Inj. Neomal 1gm/iv
Inj.pan 40mg iv/od
Inj.zofer 4mgiv/sos
Tab paracetamol 650mg/po/tid

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