Case history 5
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A 35year old male patient presented to the opd with fever and dizziness since 3 days.
Daily routine
Patient is barber by occupatin. He wakes up at 6:00am in the morning, after his daily activity . He goes to the barber shop and runs it for 2-3 hrs. Then he drink alcohol. In afternoon after taking lunch he sleeps for sometime. In the evening he again goes to barber shop. In the night he again consumes alcohol. Comes back home and takes dinner and sleep.
History of present illness
Patient was apparently asymptomatic 3 days back. Then he developed fever which was decreasing on taking anti pyretics.
He become unconscious and fell in the washroom where he injured his forehead.
Fever is insidious in onset, no diurnal variation.
Fever is associated with chills
Patient went to local hospital, where on investigation diagnosed as pancytopenia and referred to KIMS.
Past history
Patient had a history of jaundice in 2016, he used local herbal medicine for treatment. Then consumed alcohol, so he developed loose stools, watery in consistency had 20episodes per day. Then went to outside hospital,There he had altered sensorium for 3 days.
In 2018 on routine health checkup , he is fine.
There is no history of diabetes, hypertension, TB, epilepsy, asthma.
There is no history of any major surgeries.
Personal history
Patient consumes mixed diet.
Loss of appetite since 6 months.
Regular bowel movements. Decreases urine output.
Sleep is adequate.
Patient is alcoholic since 15 years consumes daily 100-180ml. Habit of chewing gutka 5-6 packets per day.
No smoking.
Treatment history
History of jaundice in the past.
No history of any drug allergy.
General examination.
Patient is concisous, coherent and co operative.
Well oriented to the place, time and person. Well nourished.
Pallor is present
Jaundice
No Vomitings
No bilateral pedal edema
No clubbing
No cyanosis
No generalised lymphedenopathy.
Vitals
Temperature:febrile
Pulse rate:120beats/min
B. P:110/70mm hg
Respiratory rate:18cycles/min
SPo2:98%
Systemic examination
Cardiovascular
S1, S2 heard.
No murmurs
Respiratory system
Bilateral airway +
Position of trachea: central
Normal vesicular breath sounds+
No crepts.
Per abdomen
Shape of abdomen:scaphoid
Tenderness is not present.
No palpable mass.
Liver and spleen not palpable.
Bowel sounds heard.
Central nervous system
Patient is concisous
Speech is normal
Reflexes are normal.
INVESTIGATIONS
ECG:
HEMOGRAM:
On 27 November
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