09/10/2021
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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
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