09/10/2021

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

A 38 year old male patient,wage worker by occupation from Murukurala,presented to the opd with chief complaints of fever since 15 days which was recurring & subsided on medication.

History of present illness:

Patient was apparently asymptomatic 15 days back then he developed fever which was recurring.

No history of cold,cough,nausea,vomiting

No history of hematuria

History of burning micturition & pedal edema.

History of past illness:

The patient was not a known case of hypertension,diabetes mellitus,bronchial asthma,epilepsy & tuberculosis.No history of any surgeries.

Personal history:

Mixed diet

Bowel & bladder - Burning micturition

Loss of appetite 

Alcoholic since 20 years

Smoker since 20 years

Family history:

No history of similar complaints in the family members.

General Examination:

The patient is conscious,coherant and cooperative.He is well oriented to time,place and person.

No Pallor

Icterus present  

No Cyanosis

No Koilonychia

No Lymphadenopathy 

Pedal Edema present

Temperature - 37 °C

Pulse rate - 72/min

Respiration Rate - 18/min

Blood pressure- 110/70

Systemic examination:

CVS : S1 S2 +

RS- Position of trachea central, vesiclular breath sounds +

L ISA Inspiratory wheeze +

L inspiratory crepitations ISA, IAA

per abdomen- scaphoid, no tenderness,

CNS- Conscious,Speech normal.

Provisional diagnosis- viral pyrexia ? hepatitis secondary to alcohol

Investigations :

Haemogram:

Complete Urine Examination:

ECG:

TPR Chart:

Ultrasound Report :

Bacterial Culture & Sensitivity Report :

Liver Function Test:

Renal Function Tests 

Serum Creatinine-1.2 mg/dl

Blood urea - 100 mg/dl

Serum electrolytes :

Sodium - 137 mEq/L

Potassium - 4.0 mEq/L

Chloride- 98 mEq/L

HBsAg - Non reactive 

HIV 1/2 Rapid test - Non reactive

Anti HCV Antibodies - Non reactive

Glycated Haemoglobin - 6.8%

Stool for Occult Blood - Negative

APTT - 33 sec

PT - 16 sec

LDH - 395 IU/L

Bleeding time & Clotting time -2 min 0 sec & 

4 min 0 sec

Malarial parasite - Negative 

Final diagnosis- Viral pyrexia with thrombocytopenia with indirect hyperbilibinemia.

Treatment -

1.IVF 1 unit of NS with optineuron 1Amp IV @50ml/ hr

2.inj. thiamine 1Amp in 100ml NS

3. Inj. Methyl cobalamine 1000 micro gram IM OD

4. Inj. Pan 40mg IV OD BBF

5.Tab azithral 500mg /PO/BD

6.Tab. udiliv 300mg PO BD

7. Bp/pr/temp charting 8th hrly

8.inform SOS

9.GRBS charting 8th hrly