Case history-7

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

A 62 year old male as come to casualty with complaint of fever and chills since 4 days .

HISTORY OF PRESENT ILLNESS:

Patient complaints of generalised headache since 4 days .

Patient also complaints of generalised body pains since 4 days .

No history of cough and cold.

No history of vomiting and loose stools 

Patient has yellowish urine.

PAST HISTORY:

Patient has no hypertension , diabetes, asthma and epilepsy .

Patient has no tuberculosis and CKD.

PERSONAL HISTORY:

Diet : mixed.

Appitite : normal.

Bowel and bladder movement: normal

Micturition: normal.

Addictions: patient has a habit of drinking of alcohol occasionally.

Patient has no other addictions like betal quid, tobacco.

FAMILY HISTORY:

No history of hypertension , diabetes, asthma , epilepsy , tuberculosis, heart diseases or stoke in the family .

TREATMENT HISTORY:

No history of surgeries , chemotherapy and radiation .

GENERAL PHYSICAL EXAMINATION:

Patient concern was taken and patient was examined in well lit room.

Patient is apparently well, coherent and cooperative .

No pallor, cyanosis , icterus, clubbing , dehydration.

No generalised lymphadenopathy.





VITALS:

Temperature : febrile 

Pulse rate : 70 beats / minute .

Respiratory rate: 18 / minute .

Blood pressure : 130/ 80 mmHg.

SpO2:99%.



SYSTEMIC EXAMINATION:


Cardiovascular system:

No thrills and cardiac mummurs .

S1 and S2 are heard .

Respiratory system:

No wheezing and dyspnoea.

Positioning of trachea is central and breath sounds are vesicular.

Abdomen:

Shape of abdomen: scaphoid.

No tenderness and no palpable mass is present.

No free fluid and bruits and liver and spleen are not palpable .
bowel sounds are heard .

Central nervous system:

Patient is conscious and speech is normal.No signs of meningeal irritation such as neck stiffness and kerning's sign.

Cerebral signs such as finger - nose in coordination and knee - heal incoordination are not present .

INVESTIGATION:

COMPLETE URINE EXAMINATION:


  
BLOOD  FOR MP STRIP TEST:


HEMOGRAM

DAY 1:

 
DAY 2:


GLYCATED HAEMOGLOBIN:



 

ULTRASOUND:



BLOOD SUGAR - RANDOMLY



PROVISIONAL DIAGNOSIS:

Viral pyrexia with thrombocytopenia.

TREATMENT:

INJ taxim 1g iv / bd 


IVF NS , RL 100 ml per hour


INJ pantop 40 mg po/ od 


INJ optineuron 1 amp in 100 ml NS / IV / OD 


TAB PCM 650 mg po / bd


Temperature, BP , PR , monitoring 4th hourly


Plenty of oral fluids 


Strict I / o charting 















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