A 35 YEAR MALE WITH FEVER AND LOOSE STOOLS

 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 patients 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 comment box is welcome.


CASE SCENARIO 

A 35 yr old male presented with 
Fever since 5 days.
Loose stools 4 days back.

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic five days ago, then he developed fever which was low grade, intermittent, relieved on taking medication, not associated with chills and rigor.

C/o loose stools- 6 episodes, non-watery, not blood stained, four days ago which has subsided now.

No h/o vomitings, pain abdomen
No h/o chest pain, palpitations, SOB
No h/o cold, cough
No h/o bleeding manifestations, purpura, bleeding gums

His platelet count as per outside reports:

19th: 64,000
20th: 11am: 30,000
           6 pm: 25,000
21st: 12,000

PAST HISTORY:

Not a k/c/o DM, HTN, Br Asthma, TB, epilepsy, CAD, thyroid

PERSONAL HISTORY:

Married
Occupation: Farmer
Appetite: normal
Diet: mixed
Sleep: reduced
Bladder and bowel movements: regular
Addictions: occasional alcohol drinker

FAMILY HISTORY:

Not significant 

GENERAL EXAMINATION:

The patient was c/c/c
Afebrile
Moderately built and nourished
No Pallor, icterus, cyanosis, clubbing, lymphadenopathy

BP:  Supine: 120/70mm Hg
        Standing: 1 min - 120/90 mm Hg
                         5 min - 110/80 mm Hg
PR:  96/min

SYSTEMIC EXAMINATION:

CVS :
 S1S2 HEARD 
no thrills no murmurs

P/A:
Non distended
Diffuse tenderness absent 
Guarding and rigidity absent

CNS: 
Patient is Conscious 
Speech: normal
No signs of Meningeal irritation
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact



INVESTIGATIONS:

— Chest Xray



— ECG



— USG abdomen



— Hemogram

    Day zero:

   Hb: 15.0%
   TC: 4100
   Platelets: 22,000

    Day one:




 Day two:



— Blood group : O+ve

— MP strip : negative

— Rapid dengue


— LFT



— RBS: 127 mg/dl

— Serum creatinine: 0.8 mg/dl
    Blood urea: 12 mg/dl

— Serum electrolytes



PROVISIONAL DIAGNOSIS: Viral Pyrexia with Thrombocytopenia - Dengue NS1

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