26 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 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 is welcome. 




Case presentation:


A 26 yr old male patient came to OPD on 1/12/2020 at 12:45pm with cheif complaints of fever since 10 days, subsided on its own and not associated with chills

Again 7 days back patient complaint of fever for 3 days associated with chills, relieved on medication ,diurnal variation present - increased during night associated with vomiting 2 episodes and vomitus contains food particles ,non bilious not associated with blood

c/o generalized weakness and myalgia since 7 days

c/o malena since 2 days

c/o cough since 15 days associated with sputum

sputum is whitish,mucoid,non foul smelly,not associated with blood

No c/o cold

No H/O burning micturition,no hematuria

No H/O diarrhoea, constipation

No H/O abdominal pain & tenderness

No H/O palpitations,chest pain, syncopal attacks


PAST HISTORY

Not a K/C/O Diabetes, Hypertension, Asthma, Epilepsy,T.B,CVA,CAD


FAMILY HISTORY

No history of diabetes , hypertension, asthama ,

Asthama, epilepsy, CAD, CA


PERSONAL HISTORY

k/C/O alcoholic since 9 years(Thrice a week)1 beer once

H/O smoking since 7 years (occasionally)

Abstinence since 1year

Diet :mixed

Sleep :adequate 

Bowel and bladder :regular

Appetite:decreased


GENERAL EXAMINATION

PT is conscious , coherent , cooperative

no pallor,icterus,cyanosis,clubbing,

lymphadenopathy,no edema

Vitals:

Temperature:99 F

Pulse:90bpm

Blood pressure:110/70mm of hg

Respiratory rate:22 cpm

SpO2:98 %at room air


CVS EXAMINATION

S1S2 heard

No murmurs


RESPIRATORY SYSTEM

Bilateral air entry present, no added sounds


PER ABDOMEN

Scaphoid abdomen,soft and no tenderness,no mass

No organomegaly


CNS

No abnormality detected


INVESTIGATIONS 


DAY 1

HAEMOGRAM 



DENGUE NS1 ANTIGEN POSITIVE - in outside reports


CUE



CHEST X RAY


ECG



LFT



RFT



RBS



BLOOD GROUPING AND TYPING



PT ,INR




DAY 2

At 6am



At 6pm


DAY 3

HAEMOGRAM

At 6 am


At 6pm

LIPID PROFILE


CHEST X RAY


DAY 4
 At 6 am


At 6pm



HBA1c



DAY 5

At 6 am






PROVISIONAL DIAGNOSIS


Viral pyrexia with thrombocytopenia 

NS1 antigen positive


TREATMENT

IV Fluids 1 NS , 1DNS, 1RL at 100ml/hr

INJ PAN 40 mg IV OD

INJ ZOFER 4mg IV OD

INJ OPTINEURON 1amp in 100ml NS IV OD

TAB DOLO 650 mg SOS

INJ NEOMOL IV Stat if Temp> 101F

TEPID SPONGING


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