20 F with pyrexia under evaluation with Thrombocytopenia

August 10, 2023

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Dr. Sarbesh Mishra

Roll no.: 142

1. COMPLAINTS AND DURATION:

20 year old female came with complaints of

fever since 1 week.

2. HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 week back then she had fever which was insidious in onset and gradually progressive, high grade, associated with chills and rigors, intermittent type for 1 day. After 1st day she had low grade fever, not associated with chills and rigors.

Patient also complaints of dry cough for 5 days (relieved now).

Patient had a history of cold (relieved now).

Patient also complaints of generalized weakness since 1 week.

Patient has a h/o vomiting (1 episode), watery, non projectile, non bilious, food particles as contents (relieved now).

She also had h/o burning micturition for 2 days (relieved now).

No H/o SOB, orthopnea or PND.

No H/O nausea, pain abdomen, loose motions, chest pain, palpitations.

3. HISTORY OF PAST ILLNESS:

Not a K/C/O DM, HTN, TB, CVA, CAD, epilepsy, asthma, thyroid disorder.

4. PERSONAL HISTORY:

Diet: mixed

Appetite-Normal

Bowel and bladder: Regular

Sleep - Adequate

No known addiction or allergies

5. DAILY ROUTINE:

She was a student but she discontinued her degree 4 years ago .

She has some tensions with regards to her father's wellbeing as he had cancer and he underwent surgery so she feels like all the burden of the family fell on her to clear the loans and take care of her parents by working at cotton plantation.

She awakens at 6 in the morning freshens up, completes her morning tasks and chores, tending to her home and laundry.

Enjoys a nutritious breakfast of rice and tasty curries to fuel her activities.

Heads to the cotton plantation, where she skillfully collects cotton.

Takes a break for lunch at 2 pm to recharge her body and mind.

Spends the day dedicated to the cotton plantation, showing her commitment and strong work ethic.

Returns home, relaxes with a bath, and unwinds by watching TV.

She has dinner at 9 pm and watches television and goes to sleep at 11 pm.

6. GENERAL EXAMINATION:

Pt is c/c/c

No pallor, icterus cyanosis, Clubbing, lymphadenopathy ,oedema .

VITALS :

Temp: 99.8 F