42 years old male with fever

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-centred online learning portfolio and your valuable comments on comment box is welcome. 

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

K.Vyshnavi
Roll No - 70


PATIENT CAME TO THE OPD,WITH THE CHIEF COMPLAINTS OF : 

Pt was apparently asymptomatic 2 days back then he had fever ,sudden in onset ,high grade , associated with chills and rigors 
Headache since 2 days frontal ,no photophobia ,no phonophobia
Generalized body pains since 2 days 

K/C/O Hansens disease 8 years back
On MB- MDT medication for 1 year And completed the medication 
Used thalidomide 100mg and prednisolone 5 years back for unknown rashes and stopped after using 6 months

On march,2022 he got fever and used medication for it and now he again got fever so was admitted  
He went to DVL OPD 
O/E Multiple hypopigmented macules noted over forehead 
Diagnosed as pityriasis versicolor
They referred him to gm opd i/v/o fever, body pains

PAST HISTORY: 

K/C/O Hansens disease 8 years back
On MB- MDT medication for 1 year And completed the medication 
Used thalidomide 100mg  and prednisolone 5 years back for unknown rashes and stopped after using 6 months

On march,2022 he got fever and used medication for it and was relieved and now he again got fever so was admitted  
He went to DVL OPD 
O/E Multiple hypopigmented macules noted over forehead 
Diagnosed as pityriasis versicolor
They referred him to gm opd i/v/o fever, body pains


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


PERSONAL HISTORY : 

Appetite -Normal 
Diet - Mixed 
Sleep - adequate
Bowel and bladder movements -Regular 
Addictions: No addictions 
Allergies : No allergies 

GENERAL EXAMINATION: 
Patient is conscious ,coherent , cooperative, thinly Built and Moderately Nourished .
He was examined under well lit room with consent taken

Temp: 102.7F
BP : 110/90 mmHg 
PR : 103bpm 
RR : 22cpm 

Pallor : absent 

Icterus : absent 

Cyanosis: absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : absent 

SYSTEMIC EXAMINATION: 

CNS : 

                   RT.                      LT 

Tone : UL : N.                       N

             LL : N.                      N

Power : UL -5/5                5/5

               LL- 5/5               5/5 


                               R   L
Reflexes : biceps: 2+ 2+

                Triceps : 2+ 2+

                   Knee: 2+ 2+

                   Ankle :2+ 2+

             Supinator : 2+ 2+

              Babinsky : 
              Plantar. Flexion on both sides 

Cereblellar signs :       R                     L

 DISDIADOKINESIA    Able.              Able
Finger nose test           +                      +
Kneel heel test.             +.                     +

Meningeal signs like : neck stiffness , kerning sign,brudzinsky sign are negative 

Sensory system -
No loss of sensations

CVS : S1 S2 + ,no murmurs 

RS : BAE Present 

P/A : Soft and Non tender 

INVESTIGATIONS

5/01/23

HEMOGRAM
Hemoglobin: 15.5
TLC: 8,900
Platelet: 3.14
MCV: 85.5
MCH: 28.5
PCV: 46.5
RBC COUNT: 5.44

6/01
Hemoglobin-14.2
TLC-6,100
PLT-1.21
PCV-43.0
RBC-5.00

7/01
Hemoglobin-14.1
TLC-5,500
PLT-50,000
PCV-43.2
RBC-4.98

8/01
Hemoglobin-10.4
TLC-5,500
PLT-50,000
PCV-43.2
RBC-3.59

6/01
ELECTROLYTES
Na: 134
Cl: 103
K: 3.5
Ca ionised: 0.95

RBS-120

RENAL FUNCTION TESTS
Urea: 34
Creatinine: 1.4

LIVER FUNCTION TESTS
Total Bilirubin: 2.18
Direct Bilirubin: 1.42
SGOT(AST): 71
SGPT(ALT): 71
ALP: 123
Total Protein: 6.8
Albumin: 3.94
A/G: 1.38

Serology - Negative
Dengue - Negative 
Blood and urine culture - negative
PROVISIONAL DIAGNOSIS-
Pyrexia with thrombocytopenia 
K/C/O HANSEN'S DISEASE with ENL with pitryiasis versicolor

Treatment-
IVF 1 unit NS and 1 unit RL @75ml/hr
Inj.neomol 1gm iv sos(if temp >/= to 101F)
Tab Pan 40mg po od
Tab.Zofer 4mg po sos
Tab.Pcm 650mg po qid
Candid TV lotion L/A OD for 3 weeks 20 minutes before bath
KZ Cream(face) L/A bd for 2 weeks




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