Case history-7

11 October , 2021

" 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"

A 16years old male presented to the opd with chief complaints of fever, vomitings, loose stools.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 5 days back then developed fever which was low and intermittent .

Fever is not associated with chills

Vomitings which were bilious and food as content.

Patient consulted nearby hospital in Nakreikal and was informed as low platelet count. 

Patient platelet count was 73,000 ,as there was no improvement seen, shifted to our hospital.

PAST HISTORY:

No history of asthma, tuberculosis, CAD, epilepsy.

No history of any surgeries in the past.

PERSONAL HISTORY:

Appetite- normal

Sleep- adequate

Bowel and bladder movement- regular

No addictions.

FAMILY HISTORY:

No history of surgeries in the family.

GENERAL EXAMINATION:

Patient is conscious , coherent and cooperative.

No clubbing

No lymphadenopathy

No icterus

No cyanosis

VITALS:

Temperature- 99degrees celsius

Pulse rate- 86 beats per minute

BP- 100/80 mmof Hg

Respiratory rate- 20cpm

SpO2- 99%

SYESTEMIC EXAMINATION:

CVS:

S1S2 heard

No murmurs

RESPIRATORY SYESTEM:

Postion of trachea- Central

BAE Present.

ABDOMEN-

Soft

Mild tenderness present in the umbilical region.

CNS:

No meningeal signs

Cranial nerves- intact

Reflexes- present

Motor and sensory system- normal

INVESTIGATIONS:

HEMOGRAM:

Hb- 13.8 gm/dl

TLC- 3,100

Neutrophils- 74

L- 75

PCV- 40.4

Platelet count - 1.57 lakhs.

CUE:

Colour- Pale yellow

Albumin- trace

Sugar- Nil 

Pus cells- 3 to 4

Epithelial cells- 2 to 3

SERUM CREATININE- 0.6

BLOOD UREA- 14

LFT:

AST- 75

ALT- 44

ALP- 295

ALB- 3.5

RBS- 89

BLOOD GROUP- O+ve

PROVISIONAL DIAGNOSIS:

Viral pyrexia with thrombocytopenia.

TREATMENT:

1. IVF 1 Unit of NS and RL IV @100ml

2. Inj.PCM IV

3. Tab PAN 40mg IV OD BBF.