A 65 year old patient with fever since 10 days

 This is an E log book to discuss our patient's de-identified health data shared after taking his guardian sign informed consent.Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problem with collective current best evidence based inputs.This E-log book also reflect my patient centered online learning portfolio.


A 65 year old male came to OPD with the chief complaint of fever since 10 days. Cough with sputum since 1 week. Burning micturition since 3 days. Decreased appetite since 10 days.


HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 10 days back then he developed fever which was of high grade and relieved on medication and it was also associated with cough and sputum since 1 week. He developed burning micturition since 3 days and decreased appetite since 10 days.


HISTORY OF PAST ILLNESS

Not a known case of diabetes mellitus,TB, asthma, hypertension.


PERSONAL HISTORY

Diet: mixed 


Appetite: normal 


Bowel movements: normal


Addictions: alcohol and tobacco smoking since 10 years.


GENERAL EXAMINATION

Patient is conscious, coherent, cooperative, well oriented to time, place and person.

No cyanosis,icterus and clubbing.


VITALS


BP-100/70mmhg


Temperature: 102 degree 


Pulse rate: 90bpm


Resp rate: 18cpm


Spo2:97%


GRBS: 122mg%


SYSTEMIC EXAMINATION

RS bae +

CVS S1 S2 +





Platelet count decreased 

Platelet count: 68000 


DIAGNOSIS 

PYREXIA with THROMBOCYTOPENIA


Treatment 

Tab dolo 650 mg po bd 

Tab sinarest po od 

INJ neomol 1 gm 

Amoxyclav 625 mg po bd 5 days







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