A 60 year old male patient came with complaint of fever , chills, rigors and loss of appetite

60 year male patient with fever ,chills, rigorand loss of appetite

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.

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
Investigations: 
Serum creatinine
Bacteria culture test 
ultrasound
Diagnosis :
Viral pyrexia with thrombocytopenia
Treatment: 

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