26 year old male with fever

26 year old male with fever





April 03, 2022
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 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-centred online learning portfolio and your valuable inputs on the 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 a diagnosis and treatment plan.

CHIEF COMPLAINT:
26 yr old, male mechanic by occupation came with c/o fever since 5 days.


HISTORY OF PRESENT ILLNESS:
The Patient was apparently asymptomatic 6 days back, then he developed fever 
which is of high grade, intermittent type associated with chills relieved with medication . 
No h/o vomitings, loose stools, burning micturition, abdominal pain. 
No h/o of sob, cough, cold.
No h/o bleeding manifestations.


PAST HISTORY:
N/k/c/o of DM, HTN, CAD , TB, BA, Epilepsy. 
No previous surgeries . 


PERSONAL HISTORY:
Diet: Mixed
Sleep: Adequate
Appetite: Normal
Bowel and bladder movements are normal
Drinks alcohol occasionally.

FAMILY HISTORY:
Not significant

DRUG HISTORY:
Not allergic to any known drug

GENERAL PHYSICAL EXAMINATION:
He is conscious, coherent and co-operative.
Vitals
Temp : 98.1 f
PR : 84 bpm 
RR : 16 cpm.
BP : 110/70 mm hg
Spo2 : 98 %@ RA
grbs : 105 mg/dl

 SYSTEMIC EXAMINATION:
CVS : s1 s2 + 
RS : Bilateral air entry present,normal vesicular breath sounds heard
CNS : NAD
P/A : soft & non tender

INVESTIGATIONS:
HB : 19.7g/dl
TLC: 3,000cells per mm^3
PCV:57ml
PLT:20,000mm^3
N/L/M/E/B: 54/34/10/2/0
RBC:6.05 million cells

UREA: 22
SR.CR:1.2
Na+:140
K+: 4.3
Cl+: 99

TB: 1.83
DB: 0.95
AST: 51
ALT:20
ALP: 128
TP: 5.5
ALB: 3.4
Dengue NS 1 : +VE 
Malarial parasite test :  -VE 


TREATMENT:
1)IVF NS, RL, @ 150 ml/hr,  DNS @ 100 ml / hr 
2)Inj. PAN 40 mg i.v OD 
3)inj. ZOFER 4 mg /i.v/ sos 
4)Inj. OPTINEURON 1amp in 100 ml NS /i.v/OD
5)Tab. DOLO 650 mg po/sos
6) Inj. NEOMOL 1gm /i.v/ sos

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