70 yr female with generalized weakness
70 yr female presented with chief complaints of
Generalized weakness from 2 days
Decreased appetite from 2 days
Vomiting from 1 day
HOPI:
patient was apparently asymptomatic 2 days back then she developed generalized weakness which is insidious in onset,gradually progressive.
Vomiting since 1day,1 episode,non bilious,non blood stained
Past history:
K/C/O HTN from 2yrs,on medication
DM from 2 yrs,not on regular medication
Present history:
Appetite- normal
Diet-Mixed
Bowel and bladder habits -Regular
Sleep- Adequate
Addictions:Pan chewing from 40 yrs
General Examination:
Patient is conscious,coherent,
co-operative
Well oriented to time, place and person moderately built and nourished
No pallor, icterus, cyanosis, clubbing, pedal oedema, lymphadenopathy
Vitals:
BP:130/80 mm Hg
PR:100bpm
Temp:98.1 F
Systemic Examination:
CVS: S1S2 Present
RS:BAE Present,NVBS
P/A:Soft, non tender
CNS:NAD
Investigations:
Provisional Diagnosis: Dengue NS1 POSITIVE with thrombocytopenia
Treatment:
1)IV fluids 1 NS 1 RL 1 Amp optineuron IV/ OD
2)INJ.CEFTRIOXONE 1 GM IV/ BD
3)T.DOXY 100 MG PO/ BD
4) T.PAN 40 MG PO/OD