32 year old male with fever and headache

Online blended bimonthly assignment for month of May 2021 

31/03/2022


Name: K. Thanmai Reddy

Roll no : 65

Batch : 2017

 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.



A 32yr old male was brought to casualty with cheif complaints of 
-fever since 1 week.
-Headache since  5 days


HISTORY OF PRESENTING ILLNESS:

  Patient was apparently asymptomatic 1 week back. Then he developed fever which is moderate to high grade, intermittent ( on and off). He visited a local  RMP and took medication. There was mild relief of symptoms.
Later his fever was remittant and high grade which was not relieved on medication and was admitted to our hospital 3days back(29/03/2022)
Fever was associated with headache which was diffuse in nature,throbbing type and not associated with photophobia or vomitings.
Patient also has body pains since onset of fever.
Patient also complained of nausea and 1episode of vomiting which was non bile stained and non projectile yesterday (30/03/2022)
The fever was not associated with:
 -chills and rigors
-vomitings
-loose stools
-burning micturition
-rash
-cold,cough
-Abdominal pain
-any bleeding manifestations (malena, hemoptysis, hematemesis)
- SOB, pedal edema, bowel disturbances

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 :
-informed consent is obtained.
-Patient is conscious, cooperative and coherent.
-moderately built and moderately nourished. 
-No  pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy or generalised edema

-Vitals:
Temp - 99°F
PR- 95bpm
BP - 110/70 mmHg
Spo2 - 99%.
RR - 20 cpm

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 the abdominal wall -moves with respiration 

No visible gastric and intestinal peristalsis

PALPATION:

 No tenderness and no local rise of temperature

No significant organomegaly

AUSCULTATION:

Bowel sounds –audible in right iliac fossa

CNS - NAD

 kernigs sign negative

Brudzinski sign negative












PROVISIONAL DIAGNOSIS 

Viral 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













31/03/2022:


FEVER CHART:(31/03/2022)



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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