26 YEAR OLD MALE WITH FEVER

November 08 ,22 .
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.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 26 yr old male who is a textile supervisor came to causality with c/o...

* Fever since 4 days 
* Body pains since 3 days 
* Headache since 3 days

History of present illness ;
 Patient was apparently asymptomatic 4 days ago then he developed a fever which is low grade with chills and rigor . Then he took the medication (paracetamol ) on his own , had the diurnal variation ( more at night time ) and not associated with any body pains or stomach ache . He came to causality with c/o

* Fever since 4 days 
* Body pains since 3 days 
* Headache since 3 days

HISTORY OF PAST ILLNESS 
N/k/h/o DM , HPT, Epilepsy, asthma

TREATMENT HISTORY
Paracetamol
Dolo - 650

FAMILY HISTORY
Not significant 

PERSONAL HISTORY
-Married
Diet         -  mixed
Appetite  -  Normal
Bowels    - regular
Micturition - Normal
Sleep          - inadequate since 4 days
Drug allergy -  no known drug allergy
Addictions  - occasionally alcoholic

GENERAL EXAMINATION
Patient is consciousness , coherent , cooperative and we'll oriented to time , place and person
Pallor        - absent
Cyanosis. - absent
Clubbing.    - absent
Icterus         - absent 
Vitals
Temp   - 97.1 F
BP.        - 130/100mmHg
PR         - 119/min
RR.        -20 cpm
SPO2.    - 99%
SYSTEMIC EXAMINATION
S1 S2 Sounds heard , no murmurs

Respiratory system
No wheezing
No dyspnea

INVESTIGATIONS 

Ultrasound

DIAGNOSIS
  Viral pyrexia with thrombocytopenia

TREATMENT
1. IVF@100ml/hr
2. Tab .Dolo 650mg T.I.D
3. Inj .Neomol 1mg IV SOS
     IF temp >/= 101°F
4. Inj . PIPTAZ 4.5mg IV /TID

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