A 32 yr /M with fever and generalized weakness

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

A 32yr old male was brought to casualty with c/o fever since 1 week.
Headache since  5 days
Generalized weakness and joint pains.
HOPI : 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.
His outside reports were 
PLT - 1.06 lakhs.

Not a k/c/o DM, HTN, thyroid, asthma, TB, CAD and, CVA.
No h/o any bleeding manifestations (malena, hemoptysis, hematemesis). 
No h/o nausea and vomitings. 
No h/o loose stools, burning micturition, cough. 
No h/o SOB, pedal edema, bowel disturbances. 
Personal history :
Diet g mixed, sleep - adequate, appetite - normal., bowel and micturition - normal. 

General examination : Patient is c/c/c moderately built and nourished. 
No  pallor, icterus, cysnosis, clubbing, lymphadenopathy or edema
Vitals:
Temp - 101F
PR-81 bpm
BP - 110/70 mmHg
Spo2 - 99%.
RR - 21 CPM
Systemic Examination :
CVS - S1 S2 +
RS - BAE +, CLEAR,, NVBS. 
P/A - soft, non tender, no organomegaly. 
CNS - NAD

Diagnosis - fever under evaluation ? Dengue. 
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. 

ECG

2D ECHO


Chest X ray

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. 

SOAP NOTES 
30/03/2022 :

S - fever spikes +, 2 episodes of vomitings
O - 
Pt - c/c/c
Temp - 102 F
PR- 86bpm
BP -  110/70mmHg
Spo2 - 99%.
RR -18 CPM
Systemic Examination :
CVS - S1 S2 +
RS - BAE +, CLEAR,, NVBS. 
P/A - soft, non tender, no organomegaly. 
CNS - NAD

A-fever under evaluation ? Dengue
Investigations 
Hb - 14.6
TLC - 9,800
PLT - 1.56 lakhs

P:
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

Comments

Post a Comment