26year old male with pyrexia under evaluation

 Dr.N.Deepa , Internee

Roll no. 105

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. 

Date of admission : 7/06/2023

CASE :

 Patient was brought to the opd with chief complaints of

Fever since 1week

c/o generalised weakness and headache since 1 week 

c/o vomitings since 3 days

c/o loose stools since 3 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently alright 1week ago then he developed fever which is high grade, intermittent, associated with chills and rigor.

He was in Orissa while he developed fever then he returned to his home 2 days later.

He also had headache and general weakness 

He developed vomitings since 3 days, 5 episodes, with food as content, non bilious, non projectile, not blood stained

Loose stools since 3 days, 3 episodes/day, watery, green coloured, not blood stained.

He went to a doctor outside but the symptoms did not subside, then he came here to our hospital.

PAST HISTORY :

No history of similar complaints in the past and no hospital admissions previously 

Not a k/c/o DM-2,HTN,TB,Asthma

No previous surgical history

No history of blood transfusions

PERSONAL HISTORY:

Normal appetite

Mixed diet

Sleep Adequate

Bowel movements - regular,  malaena +

Bladder movements- regular, hematuria+

Addictions - None

FAMILY HISTORY :

No history of diabetes or hypertension in the family.

GENERAL EXAMINATION :

Patient is examined in a well lit room after taking the consent. 

He is conscious, coherent and cooperative. 

Well oriented to time, place and person. 

Pallor - absent                 

Icterus - absent 

Cyanosis - absent

Clubbing - absent

Generalized Lymphadenopathy - absent

Bilateral pedal edema - absent

VITALS :

Pulse - 82 beats per minute, regular in rhythm, normal in volume and character of vessel, no radio- radial delay, no radio - femoral delay. 

Respiratory rate - 18 cycles per minute

Blood pressure - 100/70 mm of hg, measured in the left arm in supine position

Temperature - 100.6F

Spo2 - 98% at room air

TEMPERATURE CHARTING:

SYSTEMIC EXAMINATION : 

CVS : 

    

S1 S2 heard, no murmurs

CNS : 

No neurological deficit

RS :

Bilateral air entry present,no adventitious sounds.

ABDOMINAL EXAMINATION : 

Soft,non tender,bowel sounds+

INVESTIGATIONS:

DIAGNOSIS:

Pyrexia under evaluation - Dengue

                                            -  Clinical malaria

With AKI (resolved),ALI (resolving) with HEPATOSPLENOMEGALY with BICYTOPENIA

TREATMENT:

1.I.V fluids NS, RL, DNS@100ml/hr

2.Inj DOXY 100mg IV/BD

3.Inj. PAN 40mg IV/OD

4.INJ. NEOMOL 1gm I.V/sos if temp >102°f

5.Tab. DOLO 650mg po tid

6.Inj. ZOFER 4MG IV/TID

7.Syp. CREMAFFIN 15ML PO/BD 

8.Monitor vitals

9.Strict I/O Charting 

10.Protein rich diet

2 FFP transfusion were done in view of coagulation derangement but it was followed by reaction.The patient developed sudden excessive sneezing,cough with expectoration,high grade fever with drop in oxygen saturation. On auscultating,he had wheeze.

He is then treated with inj.AVIL , Inj.HYDROCORT and nebulizations.

The patient is now subjectively feeling better.