51 year old with fever

This is 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 patients 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 comment box is welcome."

" I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan "

51 YR OLD MALE WITH FEVER AND BODY PAINS SINCE 5 DAYS 

A 51 yr old male who is an agricultural labourer came to OPD with 

CHIEF COMPLAINTS : 

- Fever since  5 days 

- body pains since 5 days 

- loss of appetite and burning micturition since 5 days 

 - reduced appetite since 5 days 

HISTORY OF PRESENT ILLNESS: 

- Patient was apparently asymptomatic 5 days back , he then developed fever , intermittent in nature .Fever is usually low during day time , it later increases during night time , high grade associated with chills and rigors . Patient consulted a local RMP and took injections and used Dolo for fever . Fever relieved on taking antipyretic , again recurs .

- Fever is associated with intermittent episodes of headache , associated with retroorbital pain .

- Reduced appetite and  since 5 days .

- patient had intermittent dry cough for 3 days 

- he complaints of burning micturition and rescued urine output since 5 days .

- No H/O SOB , cold , nausea , vomitings , palpitations, 

Daily routine : 

 Pt wakes up at 5:30 am , he works as an agricultural labourer since 20 yrs , he has tea  breakfast around 7:30 am and goes to work in farm by 8 , at around 1 pm he has lunch ( usually rice ) , comes back home by 6 pm and relaxes , watching TV , completes dinner by 8:30 pm and sleeps by 9 pm

PAST HISTORY :

Not a K/C/O DM, HTN , ASTHMA, EPILEPSY , TB , CAD

H/O hydrocele surgery 20 yrs back 

FAMILY HISTORY : Not significant

 

PERSONAL HISTORY : 

Diet - mixed 

Appetite - reduced 

Bowel movements - regular , bladder movements - reduced 

Sleep - adequate 

Addictions : occasionally consumes toddy 

Allergies : Nil 

GENERAL EXAMINATION :

-  Patient was examined after taking his consent 

-  Patient is conscious , coherent , cooperative , well oriented to time , place and person .He is moderately built and nourished 

-  No signs of pallor , icterus , cyanosis , clubbing , oedema , lymphadenopathy 

His vitals: 

Temperature : afebrile

BP : 120/80 mm HG 

Pulse rate : 78 / min 

Resp.rate : 16 cpm

GRBS : 275 mg/dl

Systemic Examination:

CVS- S1 S2 heard,no murmurs present.

RS - bilateral Air entry present

Normal vesicular breath sounds heard

Per Abdomen : soft , non tender 

CNS :higher mental functions : normal 

Reflexes : 

MOTOR-: normal tone and power 

reflexes:

             RT      LT

Biceps ++        ++

Triceps ++          ++

Supinator ++.      ++

Knee        ++          ++

Ankle  ++             ++

Investigations:

ECG 

USG Abdomen 

Chest X Ray 

CUE 

RBS 

LFT

RFT 

Hemogram 

PROVISIONAL DIAGNOSIS:

VIRAL PYREXIA WITH THROMBOCYTOPENIA 

Management:

- Nebulisation  with salbutamol 4 respules IV/ stat

- IV fluids NS , RL @ 100 ml / hr 

- Tab . Dolo 650 mg PO / TID 

- Inj .Neomol 1 gm IV /SOS if temp > 101 F

- inj .Optinueron 1 amp in 100 ml NS PO/OD 

- syp .Citralka 10 ml PO /TID 

- plenty of oral fluids 

- strict I/O charting

- Vitals monitoring 6 th hrly

- temperature charting 4 th hrly