42 yr old male with thrombocytopenia

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.
Case presentation:
42 yr old male  Patient came with complaint of general weakness since 3 days
patient came for check up with outside reports of plts 60,000 lakh/cum with RBS 89mg/dl
patient has no history of fever,cough,cold
No H/O vertigo, tinnitus
No H/O abdominal pain, constipation, diarrhoea
No H/O burning micturition, hematuria
No H/O malena
No H/O chest pain, palpitations, syncopal attacks
No H/O SOS,Orthopnoea,PND
Not a K/C/O HT, Diabetes, Epilepsy, Asthma,TB,CNA,GAD
H/O alcoholic since 20yrs
No H/O Smoking
H/O previous surgery 20yrs back & 1 PRBC transfusion done
Diet :mixed
Sleep :adequate 
Bowel and bladder :regular
Micturition :normal
General examination: no pallor,icterus,cyanosis,clubbing,lymphadenopathy,no edema
Sytemic examination:
Cvs:s1s2 heard
No murmurs
Respiratory system:
Bilateral air entry present
Per abdomen:
Scaphoid abdomen,no tenderness,no mass
Liver and spleen not palpable
Cns:
No abnormality detected
provisional diagnosis: thrombocytopenia under evaluation
Day2
Day3
Day4
Treatment:
IVF NS@75 ml/hr
Inj optineuron 1 amp in 100 ml NS IV OD
Inj thiamine 1 amp in100 ml NS I V BD
Inj PAN 40 mg IV OD
Inj zofer 4 mg IV/SOS
Tab Dolo 650 mg PO/SOS
Tab clonazepam 0.25mg PO/HS
Tepid sponging SOS
BP,temp ,PR,RR,sPO2 monitoring
Watch for bleeding manifestations
GRBS monitoring 6th hrly

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