Viral pyrexia with Anemia
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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;
Per abdomen ;
Inspection :
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
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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