45 year old male with fever

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

CASE
A 45 year old male with  complaints of fever since 6 days ,arthralgia,Headache-4 days,Nausea since 9 days.
CHEIF COMPLANTS
C/O Fever (6days)
C/O Arthralgia (4 days)
C/O Headache (4 days)
C/O Nausea (9 days)
C/O Loose stools(5 episodes)

HISTORY OF PRESENT ILLNESS 
A 45 year male,daily worker by occupation came to casualty with complaints of high grade fever and chills and rigors relieved by taking medication associated with headache and goes off with fever.No retro orbital pain.H/O Arthralgia since 4 days.
No morning stiffness.H/O generalized weakness for 3 days.patinet sought for consultation on 2 nd day of illnesses and started on Tab oral Doxycycline 100 mg for 3 days.Now admitted for further management and treatment.

PAST ILLNESS
Patient had complaints of pedeal odema and sought for consultation and diagnosed as having Hypertension and started on Telma 40mg per oral once daily.No other co morbidities.

PERSONAL HISTORY

DIET:Mixed (non veg twice a week)

APPETITE:Normal

SLEEP: Adequate

BOWEL AND BLADDER MOVEMENT:Normal

ADDICTIONS:No Addictions

ALLERGY:No allergies known.

GENERAL EXAMINATION:
Patient is consious coherent and cooperative, well oreinted to time place and person.
Pallor:No pallor seen

Icterus: Absent 

cyanosis:Absent

 clubbing: Absent 

 lymphadenopathy- Absent.

Soft palate - petechial hemorrhage seen
No other bleeding manifestations.

VITAL SIGNS:

Bp: Supine-120/90mm Hg
      Standing:110/80mm Hg

Pulse rate: Supine:92bpm
                 Standing:90bpm

Respiratory rate:19cpm

GRBS:100mg/dl

SYSTEMIC EXAMINATION:
CVS:S1,S2 heard,no murmurs

RESPIRATORY SYSTEM:

Inspection: trachea central in position, chest moving bilaterally equally with respiration.
Palpation:
Percussion :- resonant in all the fields
Auscultation :- Normal vesicular breath sounds heard.
BAE ++
ABDOMINAL EXAMINATION:

Inspection :- no scars

Palpation :- soft,non tender

Auscultation :- BOWEL SOUNDS HEARD 

CNS EXAMINATION:

CRANIAL NERVES: INTACT 

Power

Rt UL-5/5. Lt UL-5/5 

Rt LL-5/5. Lt LL-5/5 

Tone-

Rt UL -N

Lt UL-N

Rt LL-N

Lt LL-N

Reflexes:. RIGHT LEFT

Biceps. ++ ++

Triceps. + +

Supinator. + +

Knee. ++ ++

Ankle. + +

Plantar:. Flexion Flexion       

•SENSORY

crude touch N N

              Pain N N

Temperature N N

     Fine touch N N

       Vibration Right Left

     Upper limb. 15 sec 15 sec

     Lower limb. 11 sec. 10sec

                Tibia. 14 sec. 14sec

                   Toe. 15sec. 15sec

Finger nose co-ordination : -ve
Knee-Heel coordination:-ve

Investigations
HAEMOGRAM:

APTT:
Blood grouping and RH Type:
PROTHROMBIN TIME'
SERUM ELECTROLYTES:
SERUM CALCIUM
SERUM CREATINE:
PHOSPHORUS
LFT:
BLOOD UREA:
BLOOD SUGAR RANDOM
ANTI HCV ANTIBODIES:
HSbAg
HIV:
Treatment:
1)IVF NS/RL @100ml/hr

2) INJ.PANTOP 40mg/IV/OD

3) INJ.ZOFER 4mg PO/OD 

4) INJ.NEOMOL 100ml IV 

5) T.DOLO 650mg PO/TID

6) FEVER CHARTING 4th hourly 







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