Viral pyrexia with Anemia

This is 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 patients 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 comment box is welcome .

K.shirisha

Rollno;60, 

9th semester. 

 

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 diagnosis and treatment plan. 



Case discussion;

Following is the view of my case 

Chief complaints;

A 24 year old male studied till 10th grade , occupation by shop keeper came to the hospital with chief complaints of 

*Fever since 10 days

* Cough since 10 days

* Body pains since 10 days

*Difficulty in passing stools since2 days

History of present illness;

The patient was apparently normal 1 year back then he noticed a yellowish discoloration of eyes .for which he took herbal medication and it got relieved.

Again 6 months back post Ugadi he again developed yellowish discoloration of eyes and  he visited local hospital and was told his red cells are less.and iron infusion is done once or twice a week ina hospital and 2 being at home.

At present he came to our hospital on 20/10/21

With complaints of fever since 10 days which is high grade ,onset insidious, intermittent in nature,no diurnal variations , not associated with chills and rigors.fever was relieved on medication

* Cough - dry,on and off relieved on medication

*Body pains 

*Difficulty in passing stools .he has given medication .he passed 2 episodes after taking .but he had difficulty to defecate.

*No history of abdominalpain,vomiting,sob, burning micturition,cold, palpitations, bleeding gums. Melena,hemoptysis, hematmesis.

He had recent blood transfusion.

Before this; 

Birth history;

He was born out of 3rd degree consaguious marriage.he has 2 siblings .his first brother has heart hole and he had operated at age of 2 years.now he was healthy.his second brother was also healthy.

She had birth space with 2 siblings his 2 years,3rd child is 5years.

*Three siblings are born of full term normal vaginal delivery .his birth weight was -1.2 kg at birth.not admitted in nicu due to poor facilities.

He had not breast feed since birth .he had feeden with powdermilk,cow milk. His mother tried to breast but he refused to drink  breast milk.

He had immunized.

Developmental history:


He had not achieved mile stone in a correct time. According to his mother and father . 

His gross motor,fine motor,social and adaptive,key language mile stones are delayed

He walked at age of 3 years

He talked at age of 4years

His schooling was started at age of 7 years

He used to study 1 class 2-3 years.his performance was not well he not able grasp like others.

He fears of talking tothers and riding bicycle.

He completed his 10th grade this year.

Now he is working in his shop since 6 months. He wakes up at 6am and goes out for walk and he completes his daily routines with out  taking others help.after he drinks tea at 7am.and had his breakfast at 9am.and goes to shop.and after he had his lunch at 2 pm. Afternoon he sleeps for 3 hours.and evening he plays with friends and watches atv and he takes dinner at 9am and goes to sleep.

* At the age of 6 years his parents take n him to local hospital due to delayed developmental milestones.and doctor said that his brain development is slow.beacause of their consanguinity.

Past history :

He had delayed developmental milestones.not ak/c/o hypertension,asthma, diabetes,tuberculosis,seizures, thyroid diseases

Personal history : 

Appetite: normal

Diet : vegetarian

Bowel; irregular, difficulty in passing stools since 2 days

Bladder: regular

Sleep; adequate

No addictions

Family history : his elder brother had heart hole.due to which he operated at age of 2years

General examination :

The patient is conscious coherent and cooperative

Moderately built and moderately nourished and examined under informed consent.

Pallor : present






Icterus : present


Cyanosis ; absent

Clubbing; absent

Edema; absent

Lymphadenopathy ;absent


Vitals:

Temperature : febrile

Blood pressure ; 100/60 mmHg

Heart rate; 92bpm

Respiratory rate:16cpm

Systemic examination;

Respiratory system ;

Inspection; 

Inspection of upper respiratory tract;

Oral cavity ; normal

Nose: no dns,polyp

Pharynx; normal

Lower respiratory tract;

Position of apex beat ; left 5ics 1cm medial to mid clavicular line

Symmetry of chest : symmetrical and elliptical

Movements of chest ; normal

Position of trachea ; midline

Bilateral air entry present

Palpation:

No tenderness over chest wall,no crepitations,no palpable added sounds,no palpable pleural rub

Percussion;

Resonant note heared

Auscultation; normal vesicular breath sounds heared, bilateral  air entry present

Cardiovascular system;

Inspection;
Position of trachea ;midline
No visible pulsations,no raised jvp
Precordial bulge : absent
Shape of chest; bilaterally symmetrical
Apex beat ; left 5th inter costal space1cm medial to mid clavicular line
Palpation; no palpable thrills,parasternal heaves are palpable
Percussion ; 


Auscultation; S1,S2 heart sounds are heared , no added murmurs,


Per abdomen ;

Inspection :



Shape; scaphoid
Umbilicus; central
Movements ; normal
No visible pulsations or engorged veins,no visible peristalsis
Skin over abdomen ;normal
Palpation; hepatomegaly - mild
* Splenomegaly, no tenderness,or local rise of temperature
Percussion ;
Liver; dullnote heared
No fluid thrills,shifting dullness
Auscultation;
Bowel sounds are heared

Central nervous system : 
 
Higher mental functions : 
Level of consciousness: normal
Speech : slightly slurred since childhood
Mental state;
Memory; low intelligent quotient
No meningeal signs

Cranial nerves;

1 ) olfactory nerve ; percieves smell

2) optic nerve : normal visual acuity

3) occlomotor nerve ; normal

4) trochlear nerve ;  normal

5) trigeminal nerve ; normal

6) abducens nerve ; normal

7) facial nerve; normal

8) vestibuli cochlear nerve; normal

9) glossopharyngeal nerve; normal

10)vagus nerve ; normal

11) spinal accessory nerve ; normal

12) hypoglossal nerve ; normal

Gait: normal

Motor system ;

Power  U/L         L/L

   Right   5/5        5/5

    Left      5/5        5/5

Tone        U/L                    L/L

Right       normal.        Normal

Left          Normal             Normal 

Reflexes   Biceps triceps supinator knee ankle 



Right             2+             2+            2+      2+.   2+

Left                  2+             2+.          2+.   2+.   2+

Plantar reflex: flexor

Sensory system : normal

Cerebral signs;

Finger nose in coordination; yes

Knee heel in coordination; yes

Investigations;

On 20/10/21


Blood urea-24

Ldh-554

LFT;

Total bilirubin-2.09

Direct bilirubin-0.41

AST- 30

ALT-10

ALP-112

Total proteins-6.1

Albumin-3.4

A/G ratio- 1.30

Serum creatinine- 1.1

Sodium- 138

Potassium- 3.9

Chloride-101

Hemogram;

Hb-5.7

TLC-4,400

Pcv-17.4

Rbc-1.9million/cu mm

Platelet count-1.20 lakh/cu mm

Smear ;microcytic hypochromic anemia with thrombocytopenia

21/10/21

Serum iron-100mcg/dl

RBS-89mg/dl

Complete blood picture; on 21/10/21


Smear: Anisopoikilocytosis with hypochromia with microcytes,few fenici forms,macrocytes and macro ovalocytes

Impression: Dimorphic anemia with leukopenia

22/10/21;


Serum iron;- 100mcg/dl

RBS-89mg/dl

Serum ferritin- 280.2ng/dl

Thyroid profile;

T3-1.04ng/ml

T4-12.37mcg/dl

TSH-0.71 mIU/ml

Direct coombs test - negative

Indirect coombs test- negative

Chest Xray;



Temperature chart;


Blood parasites

Reticulocyte count

Blood grouping


ECG;


Ultrasound; mild hepatomegaly,

                       Splenomegaly


Provisional diagnosis;viral pyrexia with  thrombocytopenia with anemia



Treatment; 

1) inj.Neomol 1gm iv sod

( If temperature > 101°f)

2) Tab Dolo650mg po sos

3) Tab orofer-XT po BD

4)syp.Ascoril 10ml po BD

10-x-10ml

5) syrup cremaffin -10ml po-HD

X-X-10ml

6) inform sos

On 23/10/21;


 1) inj.Neomol 1gm iv sod

( If temperature > 101°f)

2) Tab Dolo650mg po sos

3) Tab orofer-XT po BD

4)syp.Ascoril 10ml po BD

10-x-10ml

5) syrup cremaffin -10ml po-HD

X-X-10ml

6) inform sos

On24/10/21;

1) inj.Neomol 1gm iv sod

( If temperature > 101°f)

2) Tab Dolo650mg po sos

3) Tab orofer-XT po BD

4)syp.Ascoril 10ml po BD

10-x-10ml

5) syrup cremaffin -10ml po-HD

X-X-10ml

6) inform sos

7)Tab vitamin B12 1000mcgpo/OD

On25/10/21

1) inj.Neomol 1gm iv sod

( If temperature > 101°f)

2) Tab Dolo650mg po sos

3) Tab orofer-XT po BD

4)syp.Ascoril 10ml po BD

10-x-10ml

5) syrup cremaffin -10ml po-HD

X-X-10ml

6) inform sos

7) Tab vitamin B12 1000mcgpo/day

Provisional Diagnosis ; Hemolytic Anemia under evaluation



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