A 26 YEAR OLD MALE WITH ? FEVER UNDER EVALUATION WITH AKI,ALI WITH SEVERE 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"

A 26 year old male farmer by occupation came with chief complaints of 

Fever since 7 days
Pedal edema since 7 days
Loss of appetite since 5 days

HOPI - Patient was apparently asymptomatic 1 week back ,then he had one episode of low grade fever,relieved with medication,associated with generalised body pains ,not associated with cough, burning micturition.
Then developed pedal edema ,intially till ankle , gradually progressive ,pitting type.
C/o loss of appetite since 4-5 days associated with nausea .
H/o of one episode of vomiting 4 days back which is non bilious ,non projectile,food particles as content.

Past history -H/o Rat bite present 4 - 5 months back
Not a k/c/o DM/HTN/ Thyroid
Personal History
Marital history- Married
Occupation - Farmer
Diet - Mixed
Bowel & Bladder movements - Regular
Addiction- Takes alcohol occasionally 

Vitals:
Temperature - 98.7F
PR-90bpm
RR-24cpm
BP- 100/60
SpO2 - 97% at Room air 
Fever chart
No pallor/ cyanosis//clubbing/lymphadenopathy
Icterus +
Edema of feet+
 
CVS - S1,S2 +,no murmurs
RS - BAE Present,NVBS
P/A - soft ,BS +
CNS-PT CONSCIOUS,SPEECH NORMAL
CRANIAL NERVES-NORMAL

REFLEXES-
                        RT.     LFT
BICEPS-.       1+      1+
TRICEPS-.     1+     1+
SUPINATOR- 1+     1+
ANKLE.         1+       1+
KNEE-            1+      1+

Investigation
2D ECHO
ECG 6/4/22
ECG 7/4/22
ECG 8/4/22
ECG 9/4/22

USG
X - ray
HB - 20.4->20.6->19.9->20->22.3->21.6

TLC- 17,700->12,800->9640->7800->9300->8700

PLC-
60,000->35,000->46000->71000->1.10->1.50

Serum urea
129->134->104->78->59->46

Serum creatinine
4.9->4.2->2.9->2->1.5->1.2

TB
4.64->4.43->3.7->2.41->3.12

DB
3.68->2.10->1.4->1.66->1.34


Provisional diagnosis-   ? LEPTOSPIROSIS WITH SEVERE THROMBOCYTOPENIA ? SINUS SICK SYNDROME

Treatment
1. IV fluids NS ,RL@ 100 ml / hour
2. Inj . Doxycycline 100mg IV/BD
3.Inj. Pan 40 mg IV /OD
4.Inj. Optineuron 1 ampoule in 100ml NS IV /OD
5. TAB .PCM 500 mg PO / SOS
6.BP/PR/TEMP 4 th hourly

ICU Updates
7/04/22

S - No fever spikes, Appetite improved,conjuctival suffusions decreased

O - Patient is conscious, coherent and cooperative.
BP - 100/70mmhg
PR- 56Bbpm; irregular
SpO2 - 96 % on RA

CVS - S1,S2+,NO murmurs
RS - BAE present 
P/A - soft and non tender

A- SEPSIS WITH MODS SECONDARY TO ? LEPTOSPIROSIS WITH SEVERE THROMBOCYTOPENIA

P- 
1.IV FLUIDS NS ,RL @ 100ml / hour
2. Inj DOXY 100mg IV / BD
3. INJ PAN 40mg IV/OD
4.INJ OPTINEURON 1 AMP in 100 ml NS IV /OD
5.TAB.PCM 650mg PO/SOS
6.BP/PR/TEMP MONITORING

ICU Updates
8/04/22
S - No fever spikes, Appetite improved,conjuctival suffusions decreased

O - Patient is conscious, coherent and cooperative.
BP - 130/80mmhg
PR- 72 bpm
SpO2 - 96 % on RA

CVS - S1,S2+,NO murmurs
RS - BAE present 
P/A - soft and non tender

A-  ? LEPTOSPIROSIS WITH SEVERE THROMBOCYTOPENIA WITH ? SICK SINUS SYNDROME

P- 
1.IV FLUIDS NS ,RL @ 100ml / hour
2. Inj  DOXY 100mg IV / BD
3. INJ PAN 40mg IV/OD
4.INJ OPTINEURON 1 AMP in 100 ml NS IV /OD
5.TAB.PCM 650mg PO/SOS
6.BP/PR/TEMP MONITORING

AMC
9/04/22

S - No fever spikes, Appetite improved,conjuctival suffusions decreased

O - Patient is conscious, coherent and cooperative.
BP - 130/80mmhg
PR- 82 bpm
SpO2 - 96 % on RA

CVS - S1,S2+,NO murmurs
RS - BAE present 
P/A - soft and non tender

A-  ? LEPTOSPIROSIS WITH SEVERE THROMBOCYTOPENIA

P- 
1.IV FLUIDS NS ,RL @ 100ml / hour
2. Inj  DOXY 100mg IV / BD
3. INJ PAN 40mg IV/OD
4.INJ OPTINEURON 1 AMP in 100 ml NS IV /OD
5.TAB.PCM 650mg PO/SOS
6.BP/PR/TEMP MONITORING

AMC
10/04/22

S - No fever spikes, Appetite improved,conjuctival suffusions decreased

O - Patient is conscious, coherent and cooperative.
BP - 130/80mmhg
PR- 82 bpm
SpO2 - 97% on RA

CVS - S1,S2+,NO murmurs
RS - BAE present 
P/A - soft and non tender

A-  ? LEPTOSPIROSIS WITH SEVERE THROMBOCYTOPENIA

P- 
1.IV FLUIDS NS ,RL @ 100ml / hour
2. Inj  DOXY 100mg IV / BD
3. INJ PAN 40mg IV/OD
4.INJ OPTINEURON 1 AMP in 100 ml NS IV /OD
5.TAB.PCM 650mg PO/SOS
6.BP/PR/TEMP MONITORING

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