?LEPTOSPIROSIS WITH THROMBOCYTOPENIA,JAUNDICE,NON OLIGURIC RENAL FAILURE

This is an online E log book to discuss our patients deidentified health data shared after taking his/her/guardians signed informed consent.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients 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 is welcome.

Here is a case I have seen:


Unit 6 admission :

Swarna

juveria

Nikhil reddy

Divya

Manivarma



Dr. Hareen (SR)
Dr. Vinay PgY1
Dr. Vaishnavi Pgy2
Dr. Praneeth PgY3

37 yrs old male patient, Who is a daily wage labourer ,came with chief complaint of fever and generalized weakness since 5 days and loss of appetite since 4 days. 
History of present illness :
Patient was apparently asymptomatic 5 days back then he complaints of fever high grade. Fever associated with chills on and off 2-3 times/ day relieved with medication. 
Myalgia present ,went to local hospital relieved with medication .
Loss of appetite decreased since 4 days
H/o vomitings since 5 days 2 episodes and 1 episode yesterday  associated with food particles non bilious not associated with blood. 
C/O loose stools 3 episodes yesterday not associated with blood and non foul smelling 
No abdominal pain ,abdominal distension pedal edema .
No C/O SOB, orthopnea, PND
No C/O burning micturition 
No H/O HTN ,DM ,CVA, CAD, TB, Asthma epilepsy .
H/O alcoholism since 15 yrs 180 ml / day  and tobacco chewing 2 packs / day. 
Provisional diagnosis :
?ALCOHOLIC HEPATITIS? LEPTOSPIROSIS WITH THROMBOCYTOPAENIA UNDER EVALUATION
Vitals:
PR -76 bpm
BP- 110/80 mm hg
CVS- s1s2 + 
RS- BAE + clear 
O/E
Chest -barrel shaped
Petechiae present Over upperlimbs

Treatment day 1:
1. Inj. thiamine 1 amp in 100 ml NS IV TID
2.IVF 1 unit NS 1 UNIT RL at 75 ml / hr
3.Inj.PAN 40 mg IV /OD
4.Inj .ZOFER 4 MG IV/ SOS
5.Watch for bleeding manifestation 
6.BP, PR, RR ,Charting TID

Treatment day 2:
1. Inj. thiamine 1 amp in 100 ml NS IV TID
2.IVF 1 unit NS 1 UNIT DNS at 50 ml / hr
3.Inj. Ceftriaxone 1 GM IV/ BD
4.Inj.PAN 40 mg IV /OD at 8 Am
5.Inj .ZOFER 4 MG IV/ TID 
6.T.Udiliv 300 mg PO/OD
7.Watch for bleeding manifestation 
8.I/O charting 
9.BP, PR, RR ,Charting TID

Treatment day 3:
1. Inj. thiamine 1 amp in 100 ml NS IV TID
2.IVF 1 unit NS 1 UNIT DNS at 50 ml / hr
3.Inj. Ceftriaxone 1 GM IV/ BD
4.Inj.PAN 40 mg IV /OD at 8 Am
5.Inj .ZOFER 4 MG IV/ TID 
6.T.Udiliv 300 mg PO/OD
7.Watch for bleeding manifestation 
8.I/O charting 
9.BP, PR, RR ,Charting TID

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