25 Y/M with Fever and Generalised Body Pains and Headache

 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 is welcome.

CHIEF COMPLAINTS:-
Patient came to casuality with c/o Fever since 3 days
HISTORY OF PRESENT ILLNESS:-
Patient was apparently normal 3 days back, he then developed fever which is high grade, intermittent, associated with chills and rigor with evening rise of temperature
Fever associated with headache, generalised body pains and generalised weakness
Pt c/o burning sensation of eyes, loss of apetite
SOB on exertion(grade 2) since 3 days 
No c/o cold, cough, pain abdomen, burning micturition, vomitings, loose stools, chest pain. 
PAST HISTORY:-
Not a k/c/o DM, HTN, TB, Epilepsy, CVA, CAD, Asthma, Thyroid disorders. 
PERSONAL HISTORY:-
Diet - Mixed
Appetite - lost since 3 days
Bowel & Bladder - Regular
Sleep - Regular
Addictions - No
Known Allergies-No
FAMILY HISTORY:-
Insignificant
GENERAL EXAMINATION:-
Patient is conscious , coherent & co-operative
Well built and nourished.
No signs of pallor,icterus, clubbing, cyanosis, pedal edema and lymphadenopathy.

Vitals @ admission 
Temp - 98.7F
RR -17CPM
PR - 104BPM
BP - 130/90mmHg
Spo2 - 99% RA
GRBS-137 mg%
SYSTEMIC EXAMINATION:-
Respiratory system:-
BAE present, NVBS heard
Dyspnoea on exertion Grade-II
No wheeze and added sounds
Cardiovascular system:-
S1, S2 heard
No murmurs and thrills
Abdomen:-
Obese
Soft and Non tender 
No organomegaly
CNS:-
NFND
PROVISIONAL DIAGNOSIS:-
Viral pyrexia secondary to Dengue NS1 positive. 
Clinical Images:-

INVESTIGATIONS:-
Hemogram:-

Blood Urea:-

Serum Creatinine:-

Serum Electrolytes:-

Blood for MP strip:-

Dengue Rapid test:-

ECG:-

Fever chart:-


TREATMENT:-
04/05/2023:-
1)IV fluids NS, RL @ 100ml/hr
2) Inj. Optineuron 10amp in 100ml NS/IV/OD
3) Tab. PAN 40mg PO/OD
4)Tab.Dolo 650mg PO/BD
5)Inj.Neomol 1g/IV/SOS(If temp >101°F) 
6)Temp monitoring 4th hrly
7) Vitals monitoring 4th hrly

05/05/2023:-
1)IV fluids NS, RL @ 100ml/hr
2) Inj. Optineuron 10amp in 100ml NS/IV/OD
3) Tab. PAN 40mg PO/OD
4)Tab.Dolo 650mg PO/BD
5)Inj.Neomol 1g/IV/SOS(If temp >101°F) 
6)Temp monitoring 4th hrly
7) Vitals monitoring 4th hrly

Comments

Post a Comment

Popular posts from this blog

55 F WITH LOW BACK ACHE SINCE 15 YEARS

Image
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 is welcome."  CHIEF COMPLAINTS  55 year old female from Assam came with the CHIEF COMPLAINTS of lower back ache since 15 years . HISTORY OF  PRESENTING ILLNESS  Patient is a resident of Assam married at the age of 18 years ,started working in farms 4 years after her marriage ,her work many consisted of  ploughing and sowing ,transplanting the sampling requiring her to bend forward and lean for several hours (5-10hrs/day) She gave birth to her first child 2 years after marriage
Read more

49 yrs old male with HF and CKD

Image
 Chief complaints Right lower limb swelling since 10 days, fever since 5 days History of presenting illness Patient was apparently asymptomatic 10 years back then he developed progressive swelling of right lower limb and diagnosed with filariasis for which he was prescribed medicines by a local doctor 10 year back he was diagnosed with diabetes mellitus and hypertension and since then using antihypertensives( nifedipine) and anti diabetics( glizide) - 3 years back he developed pedal oedema and went for further evaluation and diagnosed to have chronic renal failure ? - 2 years back he suffered from COVID-19 following which he had shortness of breath at rest (grade 4) and chest pain for which he went to co-operate hospital in Hyderabad and diagnosed to have inferior wall myocardial infarction, So he was treated with streptokinase. At that time coronary angiogram was not done in the view of high serum creatinine levels - After 1 month coronary angiogram was done to recanalized the right c
Read more

39 year old male patient presents to casualty with complaints of shortness of breath

Image
A 39 year old male came to the casualty around 10 pm with  Chief complaints of sob since 3 days.  Fever since 10 days Cough since 10 days Chest pain since 10 days Pain abdomen since 10 days HOPI :  Patient was apparently asymptomatic 10 days back, then he developed fever associated with chills and body pains, headache, sore throat. Patient had cough which was productive with white coloured sputum. Then patient got tested positive for Widal after 4 days of onset of fever. He used symptomatic medication for a week. Then, he developed SOB since 3 days for which he got admitted in Nalgonda. SOB was insidious in onset, gradually progressed from grade 2 to grade 4 since past 10 days, SOB was more in sitting position and relieved on lying down, as his SOB aggravated, patient got shifted from that hospital and presented to our casualty. Patient also used to complain of intermittent chest pain, pain abdomen since 15 days Past History : Admitted to a hospital for pain abdomen for 4 days Not a k/
Read more