Blog 6

November 30, 2022

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 55 year old male patient, daily labourer by occupation, resident of Narketpally, came to our hospital with cheif complaint of fever.

Date of admission:- November 27, 2022

History of present illness:-

Patient was apparently asymptomatic 5 days back and developed fever which is of high grade, not associated with chills and rigors, fever is nocturnal and not relieved on taking medication and developed generalized weakness and dragging type of pain of both lower limbs since 3 days and increased frequency of stools since 3 days.

No history of cold and cough

No history of bleeding from gums

No history of hematuria

No history of rash

No history of burning micturition

History of past illness:-

Known case of Hypertension since 2 years and on medication

Not a known case of diabetes, tb, epilepsy.

Personal history:-

Patient has normal eating habit with mixed diet.

Daily routine:-

Patient used to wake up at 6.00AM , goes to work at 9.00AM, takes breakfast at 8.00AM. Then he continues with his work, takes rice in between 1.00PM-2.00PM, dinner at 9.00PM and goes to bed by 11.00PM.

Family history:-

No significant family history.

General examination:-

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

No Pallor

No Icterus

No Clubbing

No Lymphadenopathy

No Edema of feet

No Malnutrition

No Dehydration

Vitals:-

Temperature-98.6 F

Pulse rate-72 bpm

RR-14 cpm

BP-160/100 mmhg

SPO2-98% at room temperature

Investigations:-

USG abdomen

ECG

CBP

Provisional diagnosis:-

Pyrexia with thrombocytopenia

Treatment:-

IV fluids 10NS RL × 100ml per hour

Tab. Dolo 650mg × TID

Inj. Neomol 1mg × IV × SOS

Inj. Optineron × IV × OD