25 year old female with fever

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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.

On September 11, 2022

25yr old female who is a housewife by occupation came with 

Chief complaints :

Fever since 4 days

Vomiting  since 3 days

Body pains since 3 days

HOPI :

Patient was apparently asymptomatic 4 days back then she developed fever, more in the evening associated with chills relieved with medication. Then patient started having vomiting since 3 days 2-3 episodes per day with food as contents, non-projectile, non-bilious and not stained with blood. Patient had body pains since 3 days which was more in lower back, hands and legs which was not relieved with medication.

No h/o headache

No h/o diarrhea, vomiting.

Past History :

No history of similar complaints in the past.

Patient is not a known case of Diabetes mellitus, Hypertension, Tuberculosis, Asthma, Epilepsy, Thyroid disease.

There is no history of blood transfusion or hospital admission.

Personal History :

Diet : Mixed

Appetite: Normal

Sleep : Adequate

Bowel and bladder movements : Regular

Addictions : None

Family History :

No significant family history.

On examination:

Pt conscious, coherent,  cooperative, well oriented to time place and person.

Moderately built and moderately nourished.

General Examination : No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.

Clinical Images:

Systemic Examination : 

CVS- S1 S2 heard

RS- BAE present

PA - Soft, non-tender

CNS- NAD.

Investigations:

Provisional Diagnosis :

Dengue (NS1 POSITIVE ) withThromocytopenia.

Treatment :

1)INJ. NEOMAL 1gm IV if temp > 102°F

2) TAB DOLO 650mg PO/ TID

3) INJ PAN 40mg IV / OD

4) INJ ZOFER 4 mg TID/ SOS

5) IVF 10 RL @ 100 ml/ hr

6) TEMP AND VITALS MONITORING 4th hrly