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 

 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

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. 

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