41 yr old male with generalized weakness and 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-centered online learning portfolio and your valuable inputs on the comment box.


CHIEF COMPLAINTS

High grade fever since 2 days 
Generalized weakness and body pains (intermittent) since 2 days.

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 6 years ago then he developed neck pain and giddiness for which he went to RMP and was diagnosed as having hypertension started using T. Telma 20mg .Since then he was alright for 2 years and then he developed chest pain which is dragging type of pain not associated with shortness of breath and palpitations, for which he went to hospital and got an ECG done and he went to private hospital in Hyderabad and got his angiogram done and revealed nothing. He started using blood thinners as advised by them. He developed giddiness
For which he went to RMP and was detected as having diabetes and started using medication since then but was on irregular medication .

Then he was asymptomatic till 6 months and then developed generalized weakness and yellowish discoloration of sclera and involuntary fine movements and admitted to hospital and managed symptomatically. He was alright till 2 days and developed generalized weakness, high grade fever and body pains for 2 days.
H/o neck pain (on and off)
No H/o vomitings, nausea, loose stools and headache.






                            


                        


PAST HISTORY

K/c/o HTN since 6 yrs and on T.Telma 20mg/PO/OD.
K/c/o DM2 since 3yrs on OHA (poor complaince ) and stopped 3 months ago.
Asthma (+)
Not k/c/o epilepsy, TB 

PERSONAL HISTORY 

Diet -mixed 
Appetite -normal
bowel and bladder- regular
sleep -adequate
no known allergies
Addictions-Chronic alcoholic since 20 years stopped 6 months ago .
chronic smoker for 10 years stopped 10 months ago.

General Physical Examination
Patient is conscious, coherent and cooperative.well oriented to time place and person 
No pallor, ICTERUS+, cyanosis ,clubbing, generalized lymphadenopathy ,pedal edema is present.

VITALS
•Temperature-98.7°f
•Pulse rate- 86 /min
•RR- 16 per minute
•BP -100/70 mm hg
•Spo2.  98 %
•Grbs -112mg%

SYSTEMIC EXAMINATION 

•CVS : S1 and S2 heart sounds heard .No murmurs and thrills
•RESPIRATORY SYSTEM : Bilateral air entry present position of trachea - central
                                       Vesicular breath sounds heard
•CNS : NAD
•ABDOMEN : Soft and non tender
              No palpable masses
              Bowel sounds heard 
              No organomegaly

There is fine tremors of both upper limbs.

INVESTIGATIONS
                   
                             HEMOGRAM 



CUE


                                      RFT


RBS



                                     LFT



                                    ECG
     

Ultrasound

2D echo

PROVISIONAL DIAGNOSIS
Chronic liver disease with portal HTN with pancytopenia.
                
TREATMENT
•IV fluids NS @100ml/hr
•Inj. TAXIM 1gm/iv/BD
•Tab .PAN @40mg/PO/OD
•Inj. Optineuron 1amp in 100ml NS/iv
•Tab. Rifagut 5.50 mg/ PO / BD
•Tab. UDILIV 300 mg /PO/BD
•T. DOLO 650 mg/ PO/SOS
Syrup lactulose 15ml/PO
Syrup hepamerz 10 ml/PO/BD.



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