32yr old male with fever and headache

32 yr old male with fever and headache




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A 32yr old male was brought to casualty with  --fever since 1 week.
-Headache since  5 days


HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 1 week back. Then he developed fever which is moderate to high grade, intermittent ( on and off). He visited a local  RMP and took medication. There was mild relief of symptoms.
Since 4 days he is having continous high grade fever which was not subsiding with medication.
Fever was associated with headache which was diffuse in nature and not associated with photophobia or vomitings.
Patient also has body pains since onset of fever.
The fever was not associated with:
 -chills and rigors
-vomitings
-loose stools
-burning micturition
-rash
-cold,cough
-Abdominal pain
-any bleeding manifestations (malena, hemoptysis, hematemesis)
- SOB, pedal edema, bowel disturbances


PAST HISTORY:
No h/o of similar complaints in the past.
Not a k/c/o DM, HTN, thyroid, asthma, TB, CAD and, CVA.

PERSONAL HISTORY
Diet-mixed
Appetite-reduced
sleep - disturbed
bowel and micturition - normal
No addictions
No known drug and food allergies

FAMILY HISTORY:
insignificant

GENERAL EXAMINATION :
-Patient is conscious, cooperative and coherent.
-moderately built and moderately nourished. 
-No  pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy or generalised edema
-Vitals:
Temp - 101F
PR-81 bpm
BP - 110/70 mmHg
Spo2 - 99%.
RR - 21 CPM
SYSTEMIC EXAMINATION:
-CVS - S1 S2 + no murmers heard,
            apex beat loacalised at 5th intercoastal space in midclavicular line
-RS - trachea central in position, BAE +, NVBS, 
-P/A - 

INSPECTION:

Shape of abdomen – normal(not distended)

Umbilicus –central in position

Skin – no scars, sinuses,dilated veins 

Movements of the abdominal wall -moves with respiration 

No visible gastric and intestinal peristalsis

PALPATION:

Superficial Palpation – No tenderness and no local rise of temperature

Deep Palpation

No significant organomegaly

AUSCULTATION:

Bowel sounds –audible in right iliac fossa

CNS - NAD

 kernigs sign negative

Brudzinski sign negative

-there were multiple irregular hypopigmented lesions in the upper left side  of chest
-they were not associated with itching and loss of sensation.





PROVISIONAL DIAGNOSIS 
fever under evaluation ? Dengue

INVESTIGATIONS :
29/03/2022
Hemogram 
HB- 13.4, TLC-8300, PLT - 1.42 lakhs
LFT :
DB - 0.58, IB-0.17, SGOT - 66, SGOT - 64, ALT -223,
TP- 5.1, G - 3.2,  A/G - 1.73.
RFT 
Sr urea - 10, Creatinine - 0.9,
 Na/k/CL - 124/3.5/95
Dengue 
NS1, IgM, IgG- negative. 

ECG

2D ECHO


Chest X ray

Diagnosis - VIRAL PYREXIA

TREATMENT 
1.IVF NS, RL, DNS @ 100ml /hr
2.Inj PAN 40 mg po/od
3.Inj zofer 4mg IV bd
4. Inj NEOMOL IV SOS
5. TAB DOLO 650 PO/ QID
6. TAB ULTRACET PO/BD. 

 
30/03/2022 :

fever spikes +, 1 episodes of vomitings

31/3/22:
1.IVF NS, RL, DNS @ 100ml /hr
2.Inj PAN 40 mg po/od
3.Inj zofer 4mg IV bd
4. Inj NEOMOL IV SOS
5. TAB DOLO 650 PO/ QID
6.TAB naproxen 250mg BD
7.Inj. Monocef
8.clonazepam 0.25mg PO BD




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