Morning conference

July 4, 2012 Male ward Anantaporn R1/ Kanon R3

Identification data
A 58-years couple male Occupation : farmer Location : Proa, ChiangMai Data from patient ,his wife and medical record

Chief complaint

He had petechiae 3 week PTA

Present illness
12 june 2012 he had gum swelling and pain. He had bleeding per gum. He had low grade fever in the evening or midnight. He had no URI symptoms, abdominal pain, dysuria or diarrhea. 15 june 2012 he went to clinic due to gum pain. At clinic, the doctor gave him medicine by injection on his buttock. He told that the pain was relief. There was no petechiae or ecchymosis at his buttock.

Present illness
24 june 2012 he had bleeding per gum. He noticed petechiae at both legs and abdomen. He denied history of trauma. He decided to saw the doctor.

Past history
No underlying disease No food and drug allergy Hx closed fracture Lt tibia s/p ORIF(nail&plate) Hx chronic smoking 20 pack-year Hx chronic alcohol drinking 3-5 days/wk, quit 1 mouth Denied current medication Denied herbal medicine

Past history
April 2012,dentistry pulled his tooth, but no problem to stop bleeding He had two wives. The first wife live together about 2 mouths, divorce 2 years The second wife live together about 2 year. They hadnt children together. Denied IVDU Denied blood transfusion

Family history
No family history of malignancy

Physical examination
General appearance:
A middle aged man, normal consciousness

Vital signs:
Temp: 37.4 C BP: 100/60 mmHg Pulse: 100 /min RR: 18 / min O2 sat 99 %(RA)

Physical examination
HEENT: moderate pale conjuctivae, no icteric sclerae, gum hypertrophy, no bleeding per gum, no oral mucosal bleeding, no oral thrush Lymph node: Rt.axillary LN 1.5 cm, firm, movable, no tenderness Rt.inguinal LN 1 cm, firm, movable, no tenderness

Physical examination
Chest and Lung: symmetrical chest expansion with normal breathing movement, no adventitious sound Heart: PMI at Lt 5th ICS MCL No heaving, no thrill, Regular rhythm, normal S1, S2, No murmur or gallops, no carotid bruits

Physical examination
Abdomen: no distension, active BS, soft, liver just palpable, liver span 10 cm, spleen cant palpated, no tenderness, no mass Extremities: no pitting edema, no deformities. Skin: generalized petechiae at trunk, back and lower extremities

Physical examination
Neuro: Normal conscoiusness
E4 V5 M6, pupil 3 mm RTLBE Stiff neck negative Full EOM, no facial palsy Motor power grade V all Deep tendon reflex 2+ all Clonus negative both sides BBK plantar flex both sides no papilledema

Physical examination

Physical examination

Problem list

Investigation

Investigation

Investigation

Investigation

Management
Admit CBC, BUN,Cr,Elyte,Ca,Mg,Po4 LFT LDH, uric acid U/A CXR PA upright PBS Stool exam, stool conc. for parasite HBsAg, Anti-HCV Anti-HIV Set BMA+BMBx NSS 1,000 ml iv drip 100 ml/hr
Soft diet Record V/S,I/O Med NaHCO3 (500) 1*3 o pc Hydroxyurea (500) 2*2 o pc Allopurinol (300) 1*1 o pc