52 year old male with thrombocytopenia and pyrexia

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Case:

A 52 year old male who is a toddy collector by occupation and resident of Nalgonda came to OPD on 8/6/22 with the chief complaints of fever since 4 days,

decreased appetite since 3days,

tightness of abdomen since 3days.

History of present illness:

-Patient was apparently asymptomatic 4 days ago. He then developed fever of low grade, sudden in onset, gradually progressive and relieved on medication. 

-He also had complaints of abdominal distension which was gradual and progressive in nature. It is associated with pain. Abdominal pain aggravated on intake of liquids, solids. 

- abdominal tightness is also present. 

-Patient then approached local RMP and was given medication for 4 days. But symptoms recurred the next day. 

No history of rashes ,bleeding tendencies

No history of headache ,vomitings, generalised body pains

No history of loose stools , pain abdomen

No history of weight loss

Past history- 

      Not a k/c/o DM ,HTN, TB,ASTHMA,cva, cad

 Personal history :

  Diet :mixed 

  Appetite : normal

  Sleep  : adequate

  Bowel and bladder movements:regular

  Occasional alcoholic & toddy intake

Family history :

  Not significant 

General examination:

Patient is consious, coherent, cooperative.

No signs of icterus, pallor,clubbing, lymphadenopathy, edema.

 Vitals: 

Temp: 98.6 F

PR: 84 bpm

RR: 20 cpm

Grbs: 115 mg/dl

Spo2: 98%

Systemic examination

 Per Abdomen 

Inspection:

Skin - smooth (scar from childhood)

Shape - distended

Umbilicus - normal

Abdominal wall movements - present

No visible pulsations and peristaltic movements seen. 

Palpation:

Tenderness - mild

No rise of temperature

Liver - not palpable

Spleen - mild palpable 

Gall bladder - not palpable

Kidneys - not palpable

Percussion: 

Liver - dull note

Spleen - dull note

No shifting dullness, fluid thrill. 

Auscultation:

Bowel sounds heard.

No bruit. 

CARDIOVASCULAR SYSTEM- 

Inspection- 

The chest wall is bilaterally symmetrical.

No dilated veins, scars or sinuses are seen

Apical impulse or pulsations can be appreciated in sixth intercostal space 2cms lateral to mid clavicular line

Palpation-

Apical impulse is felt in the sixth intercostal space, 2 cm away from the midclavicular line

No parasternal heave or thrills are felt 

Percussion- 

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard

 RESPIRATORY SYSTEM-  

Inspection-

Chest is bilaterally symmetrical

The trachea is positioned centrally

Apical impulse is not appreciated 

Chest moves normally with respiration

No dilated veins, scars or sinuses are seen

Palpation- 

Trachea is felt in the midline 

Chest moves equally on both sides 

Apical impulse is felt in the sixth intercostal space 

Tactile vocal fremitus- appreciated 

Percussion-

The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.

They are all resonant.

Auscultation-

Normal vesicular breath sounds are heard

Central nervous system: 

No abnormalities detected

Investigations:

  Hemogram:

      Hb-14.9

       TLC-10,500

       N-43

        L-48

       E-01

      RBC-5.02

      PLT-22,000

Blood urea-59

Serum creatinine-1.6

 Serum Electrolytes-

    Na+ :141

    K+    :3.9

    Cl-   :103

 LFT

    Total bilirubin -1.27

     Direct bilirubin -0.44

     SGOT-60

     SGPT-47

      ALP-127

      Total protein-5.9

      Albumin-3.5

      A/G ratio-1.48

 CUE

    ALbumin- ++

    Pus cells -4.6

    Epithelial cells:2-3

USG :

Fatty liver (grade 2)

Mild splenomegaly

Mild pleural effusion in right lungs

 Provisional diagnosis: 

 -viral pyrexia with thrombocytopenia

Plan of treatment:

1. Ivf NS/RL/DNS continuous at 100ml/hr

2. Inj. PAN 40mg IV BD 

3. inj. ZOFER 4mg IV/SOS

4. Inj. NEOMOL 1gm IV/SOS

5. Tab. PCM 650 mg PO/ SOS

6. Inj. OPTINEURON 1 AMP in 100ml NS IV/OD over 30mins

9/6/22 

8 am 

O/E :

  Pt is conscious,coherent ,cooperative

Temp: 103 F 

Bp: 120/ 70mmhg

Pr: 90 bpm

RR: 24 cpm

SYSTEMIC EXAMINATION:

CVS:

  S1, S2 heard. No murmurs heard. 

RS: 

   Bilateral air entry present

Per abdomen:

 Soft, mild tenderness

 Shape: distended

 Bowel sounds heard.

 Treatment

Iv fluids - Ns/RL @100 ml/hr

Inj.pan 40 mg iv/OD

Inj.optineuron 1 amp in 100 ml/Ns/iv/OD over 30 mins 

Inj.zofer 4mg/iv/sos 

Tab.doxycycline 100mg PO/BD 

VITALS monitoring 

10/06/22;

Iv fluids - NS,RL@100 ml/hr

Inj.pan 40 mg iv/oD

Tab.doxycycline 100 mg Po/BD

Inj zofer 1 amp iv/sos

Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins 

VITALS monitoring 4 th hourly

 11/06/22-

Iv fluids - NS,RL@100 ml/hr

Inj.pan 40 mg iv/oD

Tab.doxycycline 100 mg Po/BD

Inj zofer 1 amp iv/sos

Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins

DOLO 650mg /sos 

VITALS monitoring 

 

    Reference blog 

https://kalpanamiryala83.blogspot.com/2022/06/final-practicals-short-case.html?m=1