26 YR OLD MALE WITH PYREXIA

26 yr old patient with pyrexia

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26 YR OLD MALE FROM NAKREKAL,DCM DRIVER BY OCCUPATION CAME TO OPD WITH CHIEF COMPLAINTS OF:

Chief complaints : 

Fever since 1 week

Generalised weakness and headache since 1 week

Vomitings since 3 days

Loose stools since 3 days

History of presenting illness:

Patient was apparently asymptomatic 1week back then he developed fever which is high grade, intermittent, associated with chills and rigor not associated with altered sensorium and relieved on medication.

He was in Orissa while he developed fever then he returned to his home 2 days later.He could not do his daily usual work due to high grade fever and headache.

He also had headache throbbing type which was sudden in onset,gradually progressive and generalised weakness since 1 week

He developed vomitings since 3 days, 3-4 episodes daily, with food as content, non bilious, non projectile, not blood stained

Loose stools since 3 days, 3 episodes/day, watery, green coloured, not blood stained.

He went to a doctor outside in anakapally but the symptoms didnot subside, then he came here on 7/6/23

H/o  green coloured stools since 3 days

Past history 

No H/o similar complaints in the past

Not a k/c/o DM, HTN, Thyroid disorders, epilepsy, asthma,TB,CAD.

Personal history 

Sleep:adequate

Appetite:normal

Diet:mixed

Bowel and Bladder:Regular and normal

Addictions:Alcohol 2 quarters daily from 6 years

On examination:

Patient is conscious, coherent and cooperative well oriented to time,place and person 

No pallor,icterus,clubbing, cyanosis, lymphadenopathy, pedal edema 

Vitals

Temp- Afebrile

PR- 86 bpm

RR- 20 cpm

BP- 100/70mmHg

RS-B/L air entry present 

      NVBS

CVS- S1S2 present, no murmurs heard

PA- Soft,non tender

CNS: NAD

Investigations 

Blood urea:52 mg/dl

Serum creatinine: 1.4 mg/dl

Serum Na+:139 mEq/L

Serum K+:4.0mEq/L

Serum Chloride:101 mEq/L

On 8/6/23

Hb: 13.3gm/dl

TLC: 900cells/cumm

Platelets: 50000 /cumm

RBC: 4.17million/cumm

Peripheral smear

RBC: Normocytic normochromic

WBC: counts decreased on smear

Platelet: counts decreased on smear

On 9/6/23

Hb: 12 gm/dl

TLC: 1300cells/cumm

RBC:3.78million/cumm

Platelets: 90,000/cumm

PCV: 35.4vol%

Serum creatinine:0.9mg/dl

Serum Na+ :139mEq/L

Serum K+: 4 mEq/L

Serum Chloride: 101mEq/L

Total Bilirubin: 4.93 mg/dl

Direct bilirubin: 3.46mg/dl

SGOT: 50 IU/L

SGPT: 18IU/L

Total proteins 5.0gm/dl

Albumin: 2.44gm/dl

A/G ratio: 0.95

On 10/6/23

On 11/6/23

Total Bilirubin: 1.57 mg/dl

Direct bilirubin: 0.65 mg/dl

SGOT: 64 IU/L

SGPT: 30 IU/L

Total proteins 4.6 gm/dl

Albumin: 2.21 gm/dl

A/G ratio: 0.92

Hb: 11.3 gm/dl

TLC: 2000 cells/cumm

RBC: 3.58 million/cumm

Platelets: 70,000/cumm

PCV: 34 vol%

On 12/6/23

Hb: 11.6 gm/dl

TLC: 2400 cells/cumm

RBC: 3.66 million/cumm

Platelets: 80000/cumm

PCV: 35.2 vol%

Total Bilirubin: 1.17 mg/dl

Direct bilirubin: 0.23 mg/dl

SGOT: 62 IU/L

SGPT: 49 IU/L

Total proteins 6.2 gm/dl

Albumin: 3.3 gm/dl

A/G ratio: 1.74

Serum electrolytes 

Serum Na+ :140mEq/L

Serum K+: 4mEq/L

Serum Chloride: 100mEq/L

Differential diagnosis

Salmonella typhi?, Entameoba hystolytica?, malaria?  With pancytopenia

Diagnosis:

Pyrexia with pancytopenia

Treatment:

1.IV FLUIDS NS, DNS, RL@ 125 ml/hr  

2.Tab.DOLO 650mg PO/TID

3.Inj.NEOMOL 1gm IV/SOS (if temp>102F)

4.Monitor vitals