60 year lo male with fever since 6 days

 

This is an 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 patient's 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 the comment box. 

A 51 year old male resident of narketpally came with Che if complaints of fever since 7 days associated with headache 

History of presenting illness 

The patient was asymptomatic 7 days back then he developed fever which was invidious in onset intermittent , low grade and relieved temporarly on taking medication . it was associated with headache ( in the frontal region ) , neck pains , back pain , body pains . 

Not associated with vomiting ,blurring of vision giddiness.

No history of blood in stools and hematuria

Past history 

No history of diabetes hypertension asthma TB epilepsy 

6 years back there was an accident ( trauma )

Personal history 

Diet : mixed 

Appetite : decreased 

Sleep : adequate

Bowel and bladder : regular

Addictions : a chronic alcoholic takes daily occasionally doesn't drink ( at least 90 ml /day ) since 30 yrs

He is a chronic smoker since 30 yrs

The person is a farmer and he came from an endemic area of dengue 

Family history 

No significant family history 

General physical examination 

Patient was conscious coherent Cooperative moderately built and nourished well oriented to time place and person

Pallor absent

Ictherus absent

Cyanosis absent

Clubbing present

Lymphadenopathy absent 

Edema absent

Temperature afebrile

Bp 110/70

RR 15

PR 69

Systemic examination 

CVS : 

On inspection : there is pectum excavatum  auscultation 

S1 S2 heard no murmors 

RS BAE + 

Per abdomen 

Shape distended 

No scars and sinus umbilicus center soft and  Non tenderness

CNS no focal neurological deficits 

Investigations

CBP: -

Platelets on day of admission 11,000 increased to 12,000the next day 

CUE :-

Colour pale yellow

Albumin +++

Pus cells 4 - 5

Epithelial cells 2- 4

RBS : 114

MP - ve

Mp strip -be

RFT: -

Urea : 35 mg/DL

Creatinine : 1.2

Uric acid : 6.1

Ca+2 : 9.9

Phosphorus : 3.5

Na+ : 138

K+ : 3.7

Cl- : 98

LFT

TB : 0.73

DB : #0.26

SGOT :#102

SGPT:#50

ALP:#234

TP:6.4

ALB : 3.7

A/G ratio : 1.35

Provisional diagnosis 

Viral pyrexia with thrombocytopenia

With NS1 +

 Treatment 

1) IVF ns , RL at 125ml/min

2) INI ZOFER 4mg IV sos

3) temp monitoring every hourly

4) Bp monitoring every 4th hourly

5) w/f bleeding manifestation

6) strict i/o charting

7) GRBS monitoring 6th hrly