A 13 yr old girl with fever , giddiness ,pain abdomen since 10 days

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I have been given this case to solve in an attempt to understand the topic of  " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

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Case history:-

A 13 yr old girl  came to the opd with chief compliants of fever since 10 days - low grade, intermittent,no diurnal variation.

Generalised weakness, burning  micturition  and vomitings since 3 days.

Vomitings -- 3 episodes, non projectile, food as content.

1 episode of bilious vomiting yesterday at 12 am.

Pain abdomen:-

Diffuse , radiating to the chest.

H/O blood colour stools and haematuria since 10 days.

NS1 - positive .. outside report.

Platelet count- 62000

 No Bleeding gums 

No Bleeding PR . 

General examination:-

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, or edema.

Vitals ;-

Temp:- afebrile

Bp :- 120/70 mm hg

PR:- 84 BPM

RR:- 22 cpm

Spo1:-97% at room air.

 

Provisional diagnosis:-

Viral pyrexia with thrombocytopenia.

Dengue NS1 positive.

Platelet count :62000

Investigations:-

 

SOAP 17/09/2021:-

S- 

Fever resolved

Patient complains of giddiness, pain abdomen, 

Dark stools, and burning micturition, vomitings 2 episodes , food as content.

O-

Patient was c/c/c

Afebrile,

Bp:- 80/50 mm hg

PR:- 76 bpm

RR:- 20cpm

Cvs:- S1, S2 present

Rs:- normal vesicular breath sounds

P/A:- tenderness present , no organomegaly.

CNS:- HMF intact.

A-

Viral pyrexia with thrombocytopenia.

P-

1. IVF NS, RL @ 150ml/ hr

2. Inj. Pantop 40 mg IV/OD

3. Inj. Zofer 4 mg IV/OD

4. Tab. Pcm 650mg po/tid

5. Syp.mucaine gel

6. Bp monitering 2 nd hrly.

7. I/O charting, temp charting, Grbs charting