25yr old woman with fever

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A 25year old woman, a homemaker from Miryalaguda came with complaints of fever since 12days, myalgia since 10days, cough since 8days

History of presenting illness

She was apparently asymptomatic 12days ago, then she developed fever which was intermittent associated with chills, with evening rise of temperature, associated with productive cough with white coloured sputum , for which she went to RMP and was given medication(unknown)

She again had fever spike for which she came to our hospital and diagnosed with Dengue fever

Past history 

History of hypothyroidism during third pregnancy and it became normal after the delivery

History of LSCS 3 months back and tubectomy was done

She is not a k/c/of Diabetes, hypertension, asthma, epilepsy, CAD

Personal history 

She has normal appetite, takes mixed diet, gets adequate sleep, has regular bowel and bladder movements, and has no addictions.

Family history

General examination

She is conscious, coherent and cooperative

She is moderately built and moderately nourished.

Pallor is present 

No icterus, cyanosis, clubbing, lymphadenopathy, edema 

Clinical images

Vitals

Temperature 99F

Pulse rate 75bpm

Blood pressure 100/70mmHg

Respiratory rate 23cpm

SpO2 98%

GRBS 110mg/dl

Systemic Examination

RESPIRATORY SYSTEM EXAMINATION

Inspection:

Bilaterally Symmetrical chest movements present 

No scars and sinuses 

Trachea central

Palpation:

Inspectory findings are confirmed

Percussion: 

Resonant note present in all lung areas

Auscultation:

Normal vesicular 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 

Auscultation

Normal bowel sounds 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

Provisional diagnosis 

Viral pyrexia 

Investigations 

TREATMENT 

Single donor platelets transfusion done on 15/8/22

Tab Doxy 100 mg PO BD 

Tab DOLO 650 mg PO SOS 

I PCM 1 gm IV SOS 

I OPTINEURON 1 Ampoule IV OD 

Inj Zofer 4mg iv (SOS)

IV Normal saline and Ringer lactate 75ml/hr