23 yr old male pt with c/c of Fever with thrombocytopenia

23yr Male with fever with thrombocytopenia

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.


PRESENTING COMPLAINTS:

Fever since 4days.

Epigastric pain since 1day.


HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 4days ago, then he got high grade fever, continuous type ,relieving on medication.

Associated with chills and rigor.

No H/O cold, cough

No H/O nausea, vomitings, headache.

No H/O burning micturation.

No H/O bleeding manifestations.


HISTORY OF PAST ILLNESS:

No similar complaints in the past.

Not a K/C/O HTN,DM,TB, Epilepsy,Asthma,CAD 


PERSONAL HISTORY:

Diet- Mixed

Appetite- Normal 

Sleep- Adequate 

Bowel and Bladder movements- Normal


FAMILY HISTORY:

No significant family history.


GENERAL EXAMINATION:

No Pallor, Icterus, Clubbing,Cyanosis, Lymphadenopathy, Pedal Edema.

Temperature- 97.3F

BP- 80/50mmhg

PR- 94bpm

RR- 18cpm

P/A- soft, tenderness over epigastric region 

Spo2- 96%@room air

GRBS- 303@ admission

CARDIOVASCULAR SYSTEM:

S1,S2 heard 

No murmurs 


RESPIRATORY SYSTEM:

BAE- present 

No wheeze

Trachea position -Central 

Breath sounds -vesicular
 

CNS:

No focal and neurological deficits

ECG:


CHEST X-RAY :

USG ABDOMEN AND PELVIS: 

LAB INVESTIGATIONS:



PROVISIONAL DIAGNOSIS:

Viral Pyrexia (Dengue fever)with thrombocytopenia.

Normocytic Normochromic Anemia.

?Denovo DM II

?AKI


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