60yr old Male with fever, chills,rigors, loss of appetite.

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Chief Complaints:

Pt complaints of fever and chills since 5 days and constipation since 4 days.

History of Present Illness:

Patient is asymptomatic since 5 days ago then developed low grade fever associated with chills and rigors. 

C/o decreased appetite since 5 days.

C/o constipation since 4days.

No H/o bleeding and dark colored stools.

Increased frequency of micturition since 1 month.

Headache, weakness on and off.

History of Past illness:

No H/o DM, BP, TB, CAD,CVD, Asthma.

Personal History:

Diet: Mixed 

Sleep:Adequate 

Appetite: Lost

Bowel and Bladder movements: Regular 

Family History:

No known similar complaints in the family.

General Examination:

Vitals: 

Temp:Afebrile

Respiratory rate:18bpm

Pulse: 86/min

Blood pressure:110/70mm hg

Sp O2 98

Systemic Examination:

Cardiovascular Examination:

Thrills: No

Cardiac sounds:S1S2 positive 

Cardiac murmurs:No

Respiratory system:

Position of trachea:Central

Breath sounds:Vesicular

Adventitious sounds: Negative

Abdomen

Shape of abdomen: Scaphoid

Tenderness:No

Palpable mass:No

Henias orifices:Normal

Free fluid:No

Bruits:No

 

Liver: not Palpable 

Spleen :Not palpable

Bowel sounds: Yes

Central Nervous system:

 Pt is conscious,coherent, co-operatively oriented to time and place.

Speech: Normal

Provisional Daignosis:

Viral pyrexia with Thrombocytopenia 

Investigation:

Diagnosis:

Viral pyrexia with Thrombocytopenia 

Treatment: