General medicine

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A 24 year old male patient, from Srirampuram, presented to the opd with chief complaints of fever since 15 days which subsided on medication, cough & body pains.

History of present illness:

Patient was apparently asymptomatic 1 year back then he had yellowish discolouration of eyes for which he took herbal medication.

6 months back he again developed yellowish discolouration of eyes & was told red cells were less & administered Iron injections weekly once.

At present, patient had fever, cough.

H/o hemoptysis, Hematemesis.

H/o recent blood transfusion.

History of past illness:

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

Patient had delyed walking & delayed talking.

Personal history:

Mixed diet

Bowel & bladder - normal

Sleep- adequate 

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.

Pallor

No Icterus   

No Cyanosis

No Clubbing

No Lymphadenopathy 

Temperature - 36.1 °C

Pulse rate - 92/min

Respiration Rate - 16/min

Blood pressure- 100/60

SpO2 - 98%

Systemic examination:

CVS : S1 S2 +

Respiratory system: BAE +

Abdomen- scaphoid, no tenderness.

CNS- Conscious,Speech normal.

Provisional diagnosis- viral pyrexia with thrombocytopenia with anemia.

Investigations :

Haemogram:

Hb - 5.7 gm/dl

TLC - 4400 cells/cumm

PCV -17.4 vol%

RBC - 1.9 million/cumm

Platelet count - 1.20 lakh/cumm

Smear - Microcytic,Hypochromic Anemia with thrombocytopenia.

Complete Urine Examination:

Normal

Albumin - nil

Sugars -nil

Malarial parasite - negative.

ECG:

 

TPR Chart:

Ultrasound Report :

Liver Function Test:

Total Bilurubin - 2.09 mg/dl

Direct bilurubin -0.41 mg/dl

AST -30 IU/L

ALT -10 IU/L

Alkaline phosphate -112 IU/L

Total Proteins -6.1 gm/dl

Albumin -3.4 gm/dl

A/G ratio - 1.30

Renal Function Tests 

Serum Creatinine-1.1 mg/dl

Blood urea - 27 mg/dl

LDH - 554

Serum electrolytes :

Sodium - 138 mEq/L

Potassium - 3.9 mEq/L

Chloride- 101 mEq/L

Questions :

Will there be any complications with use of herbal medication?