32 yr old male with fever and generalized weakness

MEDICAL ONLINE BLENDED BIMONTHLY ASSIGNMENT(MAY-2021) 

32 yr old male with fever and generalized weakness 

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NAME : Ankitha Reddy

ROLL NO : 67

A 32yr old male who is a farmer by occupation was brought to casualty with 

CHEIF COMPLAINTS : 

FEVER since 1 week.

HEADACHE since  5 days

GENERALISED WEAKNESS AND JOINT PAINS

HISTORY OF PRESENT ILLNESS:

 Patient was apparently asymptomatic 1 week back. Then he developed fever which is moderate to high grade, intermittent ( on and off) not associated with chills and rigors.

He visited a local  RMP and took medication. There was mild relief of symptoms.

— Later he had high grade and remittent Fever which was not relieved with medication so he was brought to our hospital 3 days back.

Fever was associated with headache which was diffuse in nature throbbing type and not associated with photophobia.

He feels nauseous and had 1 episode of vomiting yesterday.

Patient also has body pains and pain with eye movements since onset of fever.

Fever was not associated with chills and rigors.

No h/o any bleeding manifestations (malena, hemoptysis, hematemesis).

No h/o loose stools, abdominal pain,burning micturition, rash . 

No h/o cold, cough, SOB, pedal edema, bowel disturbances.

His outside reports were 

PLT - 1.06 lakhs.

PAST HISTORY:

No h/o of similar complaints in the past.

Not a k/c/o DM, HTN, thyroid, asthma, TB, CAD and, CVA.

PERSONAL HISTORY:

Diet-mixed

Appetite-reduced

sleep - disturbed 

bowel and micturition - normal

No addictions

No known drug and food allergies

FAMILY HISTORY:

Insignificant

GENERAL EXAMINATION :

-Patient is conscious, cooperative and coherent.

-moderately built and moderately nourished. 

-No  pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy or generalised edema

-VITALS :

Temp - 99F

PR- 95 bpm

BP - 110/70 mmHg

Spo2 - 99%.

RR - 21cycle/min

SYSTEMIC EXAMINATION:

-CVS - S1 S2 + no murmers heard,

            apex beat loacalised at 5th intercoastal space in midclavicular line

-RS - trachea central in position, BAE +, NVBS, 

-P/A - 

INSPECTION :

Shape of abdomen : normal (not distended )
Umbilicus : central in position
Skin - no scars, sinuses, dilated veins
Movements of abdominal wall : moves with respiration
No visible gastric and intestinal peristalsis.

PALPATION :
Superficial Palpation – No tenderness and no local rise of temperature.
No significant organomegaly

AUSCULTATION:

Bowel sounds –audible in right iliac fossa

CNS - NAD

Kernigs and brudzinski sign : negative 

FEVER

INVESTIGATIONS :

29/03/2022

Hemogram 

HB- 13.4, TLC-8300, PLT - 1.42 lakhs

LFT :

DB - 0.58, IB-0.17, SGOT - 66, SGOT - 64, ALT -223,

TP- 5.1, G - 3.2,  A/G - 1.73.

RFT 

Sr urea - 10, Creatinine - 0.9,

 Na/k/CL - 124/3.5/95

Dengue 

NS1, IgM, IgG- negative. 

31/03/21 : hemogram :

 

PROVISIONAL DIAGNOSIS :

Viral Pyrexia

TREATMENT : 

1.IVF NS, RL, DNS @ 100ml /hr

2.Inj PAN 40 mg po/od

3.Inj zofer 4mg IV bd

4. Inj NEOMOL IV SOS

5. TAB DOLO 650 PO/ QID

6. TAB ULTRACET PO/BD.