A 41 year old patient with fever and headache

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's 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. 

A 41 year old male resident of narketpally came with Cheif complaints of fever since 7 days associated with headache.

History of presenting illness 
The patient was asymptomatic 7 days back when he developed fever which was insidious in onset intermittent , low grade and subsided temporarly on taking medication . it was associated with headache (in the frontal
region), neck pains , back pain , body pains . 
Past history 
No history of diabetes, hypertension ,asthma, TB ,epilepsy .
6 years back there was an accident ( trauma ).
Personal history 
Diet : mixed 
Appetite : decreased 
Sleep : adequate
Bowel and bladder : regular
Addictions : a chronic alcoholic takes daily occasionally doesn't drink (at least 90 ml /day ) since 30 yrs.
He is a chronic smoker since 30 yrs.
The person is a farmer and he came from an endemic area of dengue.
General physical examination 
Patient was conscious coherent Cooperative moderately built and nourished well oriented to time place and person
Pallor absent
Ictherus absent
Cyanosis absent
Clubbing present
Lymphadenopathy absent 
Edema absent
CBP: -
Platelets on day of admission 11,000 increased to 12,000the next day 
CUE :-
Colour pale yellow
Albumin +++
Pus cells 4 - 5
Epithelial cells 2- 4

RBS : 114
MP - ve
Mp strip -be

RFT: -
Urea : 35 mg/DL
Creatinine : 1.2
Uric acid : 6.1
Ca+2 : 9.9
Phosphorus : 3.5
Na+ : 138
K+ : 3.7
Cl- : 98

LFT
TB : 0.73
DB : #0.26
SGOT :#102
SGPT:#50
ALP:#234
TP:6.4
ALB : 3.7
A/G ratio : 1.35

Provisional diagnosis 
Viral pyrexia with thrombocytopenia
With NS1 +

 Treatment 
1) IVF ns , RL at 125ml/min
2) INI ZOFER 4mg IV sos
3) temp monitoring every hourly
4) Bp monitoring every 4th hourly
5) w/f bleeding manifestation
6) strict i/o charting
7) GRBS monitoring 6th hrly.

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