38 year old male with fever since 4 days

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Chief complaints-

36 yr old male patient presented to opd with 

c/o  Fever since 4 days 

C/o of 7 episodes of loose stools 

HOPI-

Patient was apparently asymptomatic  4 days back then developed fever associated with chills and rigor , No diurnal variation,relieved with medication 

C/O Loose stools since yesterday,4-6 episodes/day,non blood stained 

H/O anorexia present since 4 days 

No H/O vomitings, decreased Urine output 

No complaints of PainAbdomen/Or any bleeding manifestations

i.e., Nohematuria/ Melena or  blood

in stool/Bleeding gums

Petechiae /rash.

No SOB/chest pain/palpitations

PAST HISTORY-

Not a k/c/o HTN, DM, CVA, CAD, TB, Asthma, or thyroid disorders. 

Allergic history:-

No history of any kind of allergies to food/drugs

Family history:- 

No significant family history 

GENERAL EXAMINATION:- 

THE PATIENT IS CONSCIOUS COHERENT AND COOPERATIVE 

NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ODEMA ; LYMPHADENOPATHY

TEMPERATURE:- 98.8 F 

PR:81bpm

BP:110/70 mmHg

RR:17cpm

SYSTEMATIC EXAMINATIONS:-

CVS:S1 S2+,NO MURMURS

CNS: NAD

RS:BAE+ ; NVBS 

P/A:SOFT ; NON TENDER ; NO ORGANOMEGALY 

PROVISIONAL DIAGNOSIS:- 

? Viral hemorrhagic fever 

? Dengue

2/9/23-

HAEMOGLOBIN

14

TOTAL COUNT

3,000

NEUTROPHILS

48

LYMPHOCYTES

41

EOSINOPHILS

00

MONOCYTES

10

BASOPHILS

01

PCV

43.8

MCV

81.2

MCH

31.3

MCHC

38.6

RDW-CV

12.7

RDW-SD

35.3

RBC COUNT

5.35

PLATELET COUNT 27000

Total Bilirubin 2.04

Direct Bilirubin 1.22

SGOT(AST) 36

SGPT(ALT) 197

ALKALINE PHOSPHATE  267

UREA 30

CREATININE 1.2 

UC 2.3 

Sodium - 136

Potassium- 3.5

Chloride - 96

NS1 - POSITIVE 

Ig M - negative

Ig G - negative

3/9/23

Hb-14.2

Total count-3000

 Plt count- 23000

 Blood urea- 30

S.creat- 1.3 

S.Na+-131

S.K+ 3.4

S.chloride- 98

SDP transfusion done on 3/8/23 6 pm

4/8/23

Hb- 13.7

Total count- 4,100

Neutrohil-50

Lymphocytes-38 

Eosinophils- 02

Monocytes-10

Basophils- 00

Pcv- 36

Mcv- 82

Platelet count-26000

Treatment-

1.I.v fluids 2 N.S @100 ml/hr

2.Tab.Dolo 650 mg Po/SOS

3.Inj. Neomol 1 gm Iv/ SOS

4.Tab.sporolac Ds Po/TID

5.Tab. Redotril 100 mg Po/OD 

6.Watch for bleeding manisfestations.