Case history-7

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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