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

 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 is welcome.

 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

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