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