50 YEAR OLD MALE WITH PYREXIA AND THROMBOCYTOPENIA WITH AKI

​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 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 inputs on the 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.

No h/o loose motions , burning micturition , dyspnea , headache , darkstools , bleeding from gums .

PAST HISTORY:-

k/c/o DM since 6 years on medication metformin 500 mg 

K/c/o HTN since 3 years not on regular medication and patient does not know the name of medication  

FAMILY HISTORY: not significant 

DAILY ROUTINE : He used to wake up at 6:00AM,Completes his needs & Breakfast by 10: Am,Then goes to his work (BARBAR).

PERSONAL HISTORY: Sleep:Adequate

                                 Diet : mixed 

                                Appetite : normal 

                                Baledder &Bowel:regular

  H/o alcohol intake daily 90 ml from 10 yrs .

GENERAL EXAMINATION:-

O/E : pt is c/c/c

No pallor , cyanosis , clubbing , 

Icterus ( ), edema upto the ankles 


VITALS:-

PR: 80 bpm

Bp: supine :110/70 mmhg 

       Prone: 110/70 mm hg 


Spo2 : 97 %

CVS : s1s2

Cns : NAD

RS: BAE

P/A: soft , Bs , NT 

       on percussion : hepatomegaly

INVESTIGATIONS:-
USG ABDOMEN: Gall bladder oedema 

:

USG OF SWELLING OVER RT MANDIBLE:-  

E/o 4.5x3cm solid cystic lesion  with solid component showing increased vascularity noted in superficial lobe of right parotid extending into deep lobe.

Enlarged 1b cervical lymph node measuring 9mm along SAD   

CHEST X-RAY:-


PROVISIONAL DIAGNOSIS:-

Viral Pyrexia with thrombocytopenia with AKI with pleomorphic adenoma with obstructive jaundice

TREATMENT:-

1) IVF NS , RL @150ml /hr 

      2)Grbs charting 8 th hrly 

      3) Temp charting hrly 

DAILY UPDATE:-

27/3/22


50year /male


S-C/o Fever , c/o vomitings subsided 


O/E:No pallor/Cyanosis/Clubbing. 

Icterus ( ), edema above the ankles 


Enlarged 1b cervical lymph node measuring 9mm along SAD  


Temp:98.4f 

PR:98bpm

RR:22cpm

BP:supine :130/90mm of hg

       Prone : 130/90mm of hg 

CVS:S1,S2 heard,no murmurs

RS:BAE ,NVBS heard

P/A:SOFT,NONTENDER,BS , Hepatomegaly ( )

A: Dx-viral pyrexia with thrombocytopenia with AKI with pleomorphic adenoma with obstructive jaundice

Rx:

1) IVF NS , RL @150ml /hr 

      2)Grbs charting 8 th hrly 

      3) Temp charting hrly 

      4) Strict I/o charting


Amc UPDATE 

28/3/22


50year /male


S-C/o Nausea , c/o fever  subsided 

O-

O/E:No pallor/Cyanosis/Clubbing. 

Icterus ( ), edema above the ankles 


Enlarged 1b cervical lymph node measuring 9mm along SAD  


Temp: 98.4 f

PR:89 bpm

RR:20 cpm

BP:supine :130/80 mm of hg

       Standing : 130/80 mm of hg 


I/O 2600/1500ml


CVS:S1,S2 heard,no murmurs

RS:BAE ,NVBS heard

P/A:SOFT,NONTENDER,BS , Hepatomegaly ( )

Hb:11.3

Plt count:20000

TLC:10600

Sr creatinine:4.9 mg/dl

Blood urea:101mg/dl

Total Bilirubin :6.30 mg/dl

Direct Bilirubin:4.42 mg/dl


Dx:-viral pyrexia with thrombocytopenia with AKI with pleomorphic adenoma with obstructive jaundice

Rx:

1) IVF NS , RL @150ml /hr 

      2)Grbs charting 8 th hrly 

      3) Temp charting hrly 

      4) Strict I/o charting

5. Inj Zofer 4mg IV /sos

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