55 yr old male with viral pyrexia and thrombocytopenia

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT .

A 55 year old male farmer by occupation, resident of Nalgonda came with the chief complains of 

Fever since 5 days which is of low grade, intermittent and relieved on local medication. Not associated with chills and rigors.
 relieved on medication.
Headache in the frontal region 
No h/o vomitings, blurring of vision giddiness,cold,cough,SOB, melena,bleeding gums,hematuria, rash.
No other complains
Went to local RMP for evaluation of fever and Ns1 was positive.  brought to our hospital in view of ns1 positive
PAST HISTORY:
No h/o   HTN, DM,TB Asthma, Epilepsy,CVD.

PERSONAL HISTORY:

DIET - MIXED,
APPETITE -REDUCED SINCE 5 DAYS
BOWEL MOVEMENT - REGULAR , 
BLADDER MOVEMENTS - REGULAR, ADDICTIONS(ALCOHOL AND SMOKING) - OCASSIONALLY TODDY HISTORY-2 BOTTLES

TREATMENT HISTORY:

NON SIGNIFICANT 

GENERAL EXAMINATION 
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
 NO ICTRUS 
 NO PALLOR 
No CLUBBING , CYANOSIS , LYMPHADENOPATHY, EDEMA
Vitals-
Temperature- 99F
PR- 64bpm
BP- 100/70mm hg(supine)
Standing-90/70 mm of hg
RR- 18 cpm
Spo2- 98%at room air








SYSTEMIC EXAMINATION 
CVS- S1 S2 heard
RS- NVBS heard
PER ABDOMEN- soft , non tender
CNS- NFND 


INVESTIGATIONS-
HB-14.1
TLC-5500
N/L/M/E-23/65/10/2
PLT-11000
PCV-41.6
RBC-4.69
Serum.urea-35
SERUM CREATININE-1.2
Na-138,k-3.7,Cl-98
Ca-9.9
P-3.7
CUE-
Colour:pale
Albumin:+++
Pus cells:4-5
Epithelial cells:2-4
MP-NEGATIVE
MP STRIP - NEGATIVE 

LFT:TB-0.73 ,DB-0.26,AST-102,ALT-50,ALP-234,TOTAL PROTEIN-6.4,ALB-3.7A/G: 1.35
RBS-114
SEROLOGY-NEGATIVE.
ECG-
 Chest X RAY



Usg: 1.Mild gall bladder  wall edema
2.grade 1 fatty liver
3.Borderline prostomegaly

 
PROVISIONAL DIAGNOSIS- VIRAL PYREXIA  with thrombocytopenia.

TREATMENT-
1.IV Fluids RL/NS @ 100 ml/hr
2. Inj.zofer 4mg IV 
3.Temperature monitoring
4.BP monitoring
5. Watch for bleeding manifestations 
6.strict I/O charting.
7.GRBS MONITORING 6th hrly



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