General Medicine Blog-11
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
