50M Fever and thrombocytopenia

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This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome."


" I’ve 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 "


CHIEF COMPLAINTS:
50 year old male patient agriculturer on occupation ame with C/o fever since 10 days




HOPI
Patient is apparently asymptomatic 10 days back and developed fever which is intermittent,high grade relieved on medication 
Associated with chills, rigor and headache 

Loss of appetite since 10 days
No history of nausea or vomiting 
Not a/s w cold,cough 
Not a/s chest pain ,palpitations,shortness of breath 
No history of trauma 
No history of burning mitcturation 


Past history:


H/o surgery: umbilical hernia : sublay hernioplasty 30 yrs ago 
Not a k/c/o Dm Htn tb asthma 

Personal history:
Appetite:decreased 
Bowel and bladder habits normal 
Diet: breakfast daily at 9:00 am  rice and dal
Skips lunch 
Next meal at 7:00pm rice and pickle 
Non vegetarian diet on weekends 
Addictions: alcoholic consumption 
(Whiskey:100 ml) regular basis 
Sleep: inadequate 

History of travel to village (haliya) 20 days back 
Did not consume food during the entire travel
Consumed whiskey 180 ml for 3 days continuously 
Fever aggravated after consumption 
Associated with sweating



General examination:

Pt is conscious coherent cooperative well oriented with time place and person 
No signs of clubbing, cyanosis, pallor ,icterus,lymphendenopathy 






Vitals :3/10 /23
Bp :130/70
PR:76bpm 
Temp:99.7
RR:18cpm 

4/10/23:
Bp:110/70
PR:80bpm
Temp: 97.7
RR: 18 cpm

:
 :








SYSTEMIC EXAMINATION :


Per abdominal examination:

Patient exposed from nipple to mid thigh and examined in supine position

INSPECTION: 

  • Shape:scaphoid

  • Umbilicus: central

  • Skin over the abdomen is normal

  • No visible peristalsis, 

  • No Visible superficial vessels

  • External genitalia normal


    Palpation:
    On superficial Palpation
    All inspectory findings are confirmed
    No local rise of temperature
    Tenderness+
    No Rebound tenderness

    • No guarding,rigidity

      No organomegaly

      Percussion:

      Shifting dullness nil

      fluid thrill nil

      Auscultation:

      Bowel sounds heard







      RESPIRATORY SYSTEM

      Inspection 

      • Shape of chest:Bilaterally symmetrical,Elliptical in shape

      • No visible chest deformities

      • Abdomino thoracic respiration,No irregular respiration

      • No tracheal shift

      • No dropping of shoulders, on both sides,no sinuses,scars,engorged veins


      Palpation:inspectory findings confirmed by Palpation 

      • Chest movements -normal


        Percussion:

        Resonant note heard over all areas except right infra mammary area

        Auscultation:

        Norma vesicular breath sounds

        , breath sounds normal

        Vocal resonance:Decreased in basal areas


        Cardiovascular system:

        Inspection:precordium normal,apex beat :5th ICS half inch medial to mid clavicular line

        Palpation:inspectory findings confirmed,No thrills or parasternal heave


        Auscultation: S1S2+,no murmurs


        CNS:

        HMF normal, Awake and oriented

        cranial nerves intact,motor and sensory examination normal

        No cerebellar or meningeal signs












Provisional diagnosis:
? Viral pyrexia under evaluation with thrombocytopenia?viral hepatits 

Investigation: 3/10 /23
RBS - 141 mg/dl
TB - 0.60mg/dl
DB - 0.18 mg/dl
AST -133# IU/l
ALT - 154#IU/l
ALP - #383IU/L
TP - 6.8 gm/dl
Alb - #3.16
A/G ratio -0.87
Blood urea -43#/dl
Ser creat -1.2 mg/dl
Uric Acud - 4.4 mg%
Na -#130
K - 4.0
Cl - 99
Ca - 1.20
Hb - # 11.8
Tlc - #7600
Pcv:34.1#
Mchc:34.6#
Platelet:1.0 IU
Cue - alb and sugars nil

X-ray:





Treatment given: 3/10/2023

IV fluilds 0.9% NS @75 ml /hr 
TAB DOLO 650mg PO/BD 
INJ NEOMOL1gm Iv 
INJ THIAMINE  200 mg in 100 ml NS 


Fever chart @4pm
101.2
















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