GENERAL MEDICINE 3
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A 45 yr old male patient farmer by occupation came to opd with cheif complaint of fever since 5 days
HISTORY OF PRESENT ILLNESS
Patient was asymptomatic 5 days back when he went for farming in the morning and when he returned to home he noticed shivering headache and raise in temperature.
Patient has taken a paracetemol and fever subsided when he woke up in the morning he again noticed a raise in temperature
Then patient consulted a local RMP and he adviced for a CBP
based on CBP RMP diagnosed there is decreaed in tha platelets count and adviced for a higher speciality hospital.
Then patient visted a higher speciality hospital and got admited there
PAST HISTORY
no history of DM ,hypertension ,epilepsy,TB
No history of any surgeries in the past
Patient complaints of cough when he is weak or during fever from childhood .
FAMILY HISTORY
no relavent family history
PERSONAL HISTORY :
Diet : mixed
Sleep : adequate
Bowel and bladder regular
Apatite : normal
Addictions : consumption of alchol occasionally since 20 yr
DRUG HISTORY :
no allergy to known drugs
GENERAL EXAMINATION :
Patient was concious, coherent ,well built ,
Well nourished .
No pallor
No cynosis
No icterus
No pallor
No pedal edema
VITALS :
Temp : 98.8⁰F
Pulse : 70 beats /min
Resp : 18 cycle /min
BP : 130/90 mm hg
SYSTEMIC EXAMINATION :
CVS : S1 and s2 are heard , no cardiac murmmers
CNS : consicious , normal speech
Respiratory system : no wheezing sounds
Position of trachea is central breathing sounds vehicular
Perabdomen :
Shape of abdomen : scaphoid
No palpable mass
No tenderness
Liver : not palpable
Spleen : not palpable
INVESTIGATIONS :
26/10/2021
Hb : 14.5 gm /dl
Total WBC : 7,100 cells /ccmm
RBC : 5.06 million / ccmm
Platlet : 70,000 laks / ccm
Blood for MP : strip test negitive
URINE EXAMINATION:
colour : pale yellow
Appearance : clear
Albumin : negitive
RBC : nil
Sugar : nil
Epithilial cells : 2- 3
Pus cells : 2-4
27/10/2021 :
Hb : 15.3gm/dl
Total WBC : 8,800 cells / ccmm
RBC : 5.31 million /ccm
Platelet count : 62,000 / ccm
29/10/2021 :
Hb : 15.3 gm/dl
RBC : 5.29 million /cmm
WBC : 8,400 cells / cmm
Platelet count : 1,30 ,000 /cmm
Ultrasound :
DIAGNOSIS : viral Pyrexia with thrombocytopenia
Treatment :
26/10/2021
iv NS at 100 ml / hr
Iv RL at 100ml /hr
Inj . Optinguron 1amp in 100 ml NS iv /OD
Tab . PCM 650 mg BD
Inj.PAN 40 mg Iv /OD
Lots of oral fluid
27/10/2021
iv NS at 100 ml / hr
Iv RL at 100ml /hr
Inj . Optinguron 1amp in 100 ml NS iv /OD
Tab . PCM 650 mg BD
Inj.PAN 40 mg Iv /OD
Lots of oral fluid
Inj.taxim 1g iv/BD
28/10/2021
iv NS at 100 ml / hr
Iv RL at 100ml /hr
Inj . Optinguron 1amp in 100 ml NS iv /OD
Tab . PCM 650 mg BD
Inj.PAN 40 mg Iv /OD
Lots of oral fluid
Inj.taxim 1g iv/BD
29/10/2021
iv NS at 100 ml / hr
Iv RL at 100ml /hr
Inj . Optinguron 1amp in 100 ml NS iv /OD
Tab . PCM 650 mg BD
Inj.PAN 40 mg Iv /OD
Lots of oral fluid
Inj.taxim 1g iv/BD
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