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Diagnosis?

GENERAL DATA: This is a case of TC, a 49-year old, male, married. CHIEF COMPLAINT Fever HISTORY OF PRESENT ILLNESS: History of Present Illness: 8 days prior to admission, patient experienced sudden onset of frontal headache, throbbing, non radiating, 8/10 pain scales, continuous, accompanied by body malaise, no other associated signs and symptoms of fever, cough, colds, difficulty of breathing, chest pain, dizziness, nor changes in bowel movement. Patient self medicated with Paracetamol 500mg/tablet which provided temporary relief. No consult done. 5 days prior to admission, above signs and symptoms persisted but now accompanied by intermittent fever, Tmax: 38.2C, calf pain, described as compressing, 7/10 pain scale, myalgia, and redness of the eyes. No other associated signs and symptoms of abdominal pain, chest pain, cough, colds, sore throat, nor rashes. Patient sought consult at private MD, where CBC, urinalysis and dengue duo were requested (see appendix I). Results showed leukocytosis with predominance of neutrophils, lymphocytopenia, and thrombocytopenia, Urinalysis result showed unremarkable, dengue duo revealed negative results. Patient was diagnosed as dengue fever and was advised for admission but no vacancy noted and was advised to transfer to other hospital but instead, patient went home. 4 days prior to admission, above signs and symptoms still persisted now accompanied by loss of appetite, epigastric pain, crampy, non radiating, 4/10 pain scale, 1 episode of vomiting, 1cup, watery vomitus admixed with food particles, non bilous, non bloody, patient then sought consult at a government hospital where CBC was done (see appendix I) which revealed an increased in leukocytes and neutrophil and decreased in lymphocytes and platelet in comparison from the one done yesterday. Patient was still diagnosed with dengue and was advised for admission but opted to go home. Interim, above signs and symptoms still persisted, patient took Paracetamol 500mg/tablet, 1 tablet as needed for fever. No consult done. Few hours prior to admission, with the persistence of the above signs and symptoms, now accompanied by non productive cough, no other associated signs and symptoms of difficulty of breathing, chest pain, no recurrence of vomiting, nor diarrhea, patient prompted to seek consult hence admitted. PAST MEDICAL HISTORY: (-) Hypertension (-) Diabetes mellitus (-) Myocardial infarction (-) Bronchial Asthma (-) PTB (-) Stroke (-) Cancer (-) Allergy (-) Previous surgeries FAMILY MEDICAL HISTORY: (+) Hypertension - Paternal (-) Diabetes Mellitus (-) Bronchial Asthma (-) Lung disease (-) PTB (-) Heart disease (-)Stroke (-) Malignancy PERSONAL AND SOCIAL HISTORY: 3 pack year smoker Occasional alcoholic beverage drinker, 1bottle of gin/session Denies illicit drug use Driver History of wading in the flood, 2 weeks ago REVIEW OF SYSTEMS: General : (-) weight loss, (-) chills, (-) fatigue Integumentary : (-) rash, (-) petechiae, (-) erythema, (-) abnormal pigmentation, (-) alopecia Head and Neck : (-) tinnitus, (-) hearing loss, (-) dryness of the mouth, (-) head trauma, (-) eye pain, (-) eye discharge, (-) voice hoarseness Respiratory : (-) hemoptysis, (-) wheezing, (-) Back pain, (-) Orthopnea, (-) Trepopnea Cardiovascular: (-) palpitations, (-) orthopnea, (-) paroxysmal nocturnal dyspnea, (-) orthopnea, (-) easy fatigability, (-) palpitations Genitourinary: (-) dysuria, (-) oliguria, (-) tea-colored urine, (-) urinary incontinence, (-) nocturia, (-) urinary urgency, (-) urinary retention Musculoskeletal: (-) myalgia, (-) joint swelling, (-) joint pains, (-) erythema Endocrine: (-) polydipsia, (-) polyuria, (-) heat or cold intolerance, (-) palpitation, (-) excessive sweating Hematologic: (-) easy bruisability, (-) pallor Dermatologic: (-) oral ulcers, skin discolorations Neuro-Psychiatric: (-) depression, (-) sleep disturbance, (-) anxiety, (-) hallucinations PHYSICAL EXAMINATION: GENERAL SURVEY: Awake, coherent, not in cardiopulmonary distress Vital Signs:BP: 140/80 mmHg HR: 125 bpm RR: 24 cpm Temp: 38°C Anthropometric Measurement: Ht. 5’9” Wt. 62 kgs BMI: 20.18 kg/m2 (Normal) SKIN: Jaundice, warm, moist skin, with good turgor, no active dermatoses HEENT: Pink palpebral conjunctiva, icteric sclera, (+) conjunctival suffusion, no opacities, moist buccal mucosa, no palpable cervical lymphadenopathy, thyroid gland not enlarged, (-) jugular vein distention CHEST AND LUNGS: No deformity, no retractions, symmetrical chest and chest expansion, equal vocal and tactile fremitus, (+) crackles, left lung base HEART: Adynamic precordium, apex beat at the 5th ICS LMCL, no lifts, thrills or heaves, tachycardic, regular rhythm, no murmur ABDOMEN: Flat abdomen, umbilicus inverted, no visible vessels, no scars, normoactive bowel sounds, soft, no epigastric tenderness, no masses noted EXTREMITIES: no cyanosis, no edema, pulses full and equal on all extremities, tenderness on both calves

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Concluded answer

Leptospirosis

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Whole saga of history could be understand but annuxres of investigations are not seen Simply post xray chest usg report LFTS KFTS cbc esr crp sr ferritin D-dimer From data given looks to be a c/o alcoholic hepatitis or pancreatitis Presentation is failing to assess his diabetic status which is most important Dear dr from 1st day to last no one has assessed and examined him throughly Right now i only can say hospitalise and workout throughly

Thanx dr Pushkar ji Bhomia
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NEED'S.. HOSPITALIZATION .. CLINICOPATHOLOGICAL EVALUATION WITH.. HEMOGRAM.. ANEMIA PROFILE.. URINE ROUTINE.. LFT..KFT.. BSR..HBA1C.. CXR..STUDY.. USG..ABDOMEN.. MEANWHILE TREAT SYMPTOMATICALLY WITH CLINICAL CORRELATION..

Tnx Dr Shivraj Agarwal sir
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Leucocytosis Thrombocytopenai Find out cause of this Xray chest Urinert Dengue every12 hr cbc For pletelet not dropping less then 10000 Other wise admit sm drip

Good briefing of case. Need to review CBC, HRCT thorax, Must transfuse blood and/or platelets .. if PC is <20000. Jaundice must be taken care for.

T C Blood transfusion Packed platelets in siliconised bottle transfusion

Leptospirosis

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