35 yr old male with fever,since 2 months and bicytopenia

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 35 yr old male who works for oil factory as supervisor

Patient had chief complaints of fever since 2 months on and off , low grade fever,increased during night,relieved on medication; gradual onset; associated with chills, pt had been feeling  cold since 10 days.

No complaints of cough, abdominal pain, dysphagia, head ache,burning micturition,

Patient had complaints of weight loss approximately 7 kgs since 2 months

Patient had no H/O vomitings, nausea.

Complaints of decreased appetite associated with indigestion

Patient had complaints of constipation , passing stools once for 6-7 days

No wounds,abscess or skin infections

History of present illness: no c/o SOB, orthopnea, syncope.

No c/o chest pain, palpitations 

C/o headache during episode of fever on right temporal side

No c/o burning micturition.

History of past illness: not a k/c/o DM, HTN, epilepsy, asthma,TB.

Personal history: 

Appetite: decreased

Bowels: irregular , passing stools once for 5-7 days

Bladder movements - normal 

alcholic since 10 years 90ml / 2 days last binge was 7 months back.. and abstinence since 2 months

Non smoker but takes chewable tobacco 1 packet for 5 days

Family history:

No history of DM, HTN CAD, CVA, aasthma in the family

General examination: patient is conscious, coherent, cooperative 

Pallor is seen.

No icterus, cyanosis, clubbing,lymphadenopathy, edema

Vitals:

Temp:98.5F

Pulse: 80bpm

Respiratory rate: 19/ min

Bp: 110/80 mm hg

SpO2-99% in room air

Systemic examination: 

vs: S1 S2 heard no additional sounds or murmurs

Rs: NVBS

Abdomen: soft,non tender

Cns: higher mental functions intact 

Provisional diagnosis:  fever with bicytopenia

 

Day 2 haemogram

Treatment:

Inj neomol 1g iv sis if temperature>101F

Tab PCM 650 mg po/sos

Tab MVT OD

Syp.lactulose 10ml TID

Tepid sponging

Temperature charting

BP,PR,RR,spO2 monitoring

I/o charting