Case 5

 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 45 year old male presented to OPD with chief complaints of fever and chills since 4 days.

HISTORY OF PRESENT ILLNESS 

Patient was apparently alright 4 days back then he develope muscle cramps and cough initially

No history of chest pain, pedal edema,blurring of vision,loose stool.


HISTORY OF PAST ILLNESS

No history of diabetes, asthma, CAD, hypertension, tuberculosis, previous surgery 


PERSONAL HISTORY 

Diet-Mixed

Appetite-Normal

Bowels-regular

Sleep-normal


FAMILY HISTORY 

No history of hypertension, diabetes, heart disease, asthma,cancer, tuberculosis 


GENRAL EXAMINATION 

Patient is conscious,coherent, co-operative and well oriented to time and place 

There is no sign of pallor,oedema of left foot

There is no sign of cynosis,lymphadenopathy 


VITALS

Temperature-febrile

Pulse rate - 70/min

Respiratory rate-18/min

BP-130/90

SPO2-99%


SYSTEMIC EXAMINATION 

Thrills-No

Cardiac sound-S1,S2

Cardiac murmer-No

RESPIRATORY SYSTEM 

Dyspnoea-No

Wheeze-No

Position of trachea-Central

Breath sounds-Vesicular

ABDOMEN 

Shape of abdomen-scaphoid

No tenderness 

No palpable mass

No Free fluid 

No bruits

Liver and spleen- not palpable

Bowel sound-yes

CENTRAL NERVOUS SYSTEM 

Patient is conscious 

Speech-normal

Motor and sensory system-Normal


PROVISIONAL DIAGNOSIS 

Viral Pyrexia with thrombocytopenia







INVESTIGATION 

26th October 





27th October 








TREATMENT 

TREATMENT GIVEN:

-Inj TAXIM 1G IV/BD 

-IVF-NS, RL @100ml /hr 

-Inj PAN 40 mg PO/OD 

-Inj OPTINEURON 1amp in 100 ml NS/IV/OD 

-Tab PCM 650 mg PO/BD 

-strict I/O charting 

-Temp,BP,PR monitoring 

-plenty of oral fluids


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