General Medicine Case Presentation


I have 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 a diagnosis and treatment plan.

A 40 year male , farmer by occupation came to the casualty with the chief complaints of :
1. Complaint of fever since 5 days.
2. History of vomiting 5 days back.

The patient was apparently asymptomatic 5 days back, then he took the Covid Vaccination. Since then he is having fever associated with chills and rigor, no diurnal variation, not associated with sweating, subsided on taking medication.

There was history of 2 episodes of vomiting 5 days back which was non bilious, non projectile and was not associated with pain abdomen.

The patient had no complains of headache, palpitations, shortness of breath or pedal edema.

The patient is not a know case of Hypertension or Diabetes Mellitus.
The patient is a known alcoholic since 20 years.
The patient is a non smoker.

Vitals at the time of admission :
Temperature - 96.7 F
Blood pressure - 70/50 mm Hg
Pulse Rate - 80bpm
Respiratory rate - 18cpm
SpO2 at room air - 97%
CVS -. S1 S2 present
CNS - HMF intact
RS - BAE + , crepts present
P/A - soft, tenderness present in right Hypochondrium.

General Examination :
Investigations :
Diagnosis :  
Fever with Thrombocytopenia with Anemia under evaluation with AKI.

Treatment :
1. Intravenous fluids - NS, RL, DNS at 100ml/hr.
2. Injection PANTOP 40mg / IV/ OD
3. Injection ZOFER 4mg /IV / SOS
4. Tablet DOLO 650mg / PO / TID
5. Injection OPTINEURON 1ampule in 1 unit NS / IV / OD
6. Injection NEOMOL 100ml / IV / SOS
7. Tablet ULTRACET PO / QID 
        1/2 - 1/2 - 1/2 - 1/2
8. Watch for bleeding manifestations
9. Monitor vitals.

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