19 year old male



 19 year old came with complaints of fever since 5 days

This is 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 patients 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 comment box is welcome .

19 year old male came with chief complaints of Fever  since 3 days

Pain abdomen since 3 days

Low back ache since 3 days

Generalised weakness since 3 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3 days back then he developed fever which is insidious in onset , gradually progressive not associated with chills and rigors 

C/O pain abdomen insidious in onset , diffuse type not associated with nausea /vomiting

C/O low back ache ( insidious , gradually progressive ) not associated with tingling /numbness

C/O Generalised weakness since 3 days

PAST HISTORY:

History of fever 10 days back which was diagnosed as typhoid and was given oral medication for 3 days and iv medication for 1 day

No history of Hypertension, diabetes, asthma, epilepsy,TB

No history of prolonged hospital stay

No history of previous surgeries

Not a k/C/o DM , HTN , TB , EPILEPSY 

PERSONAL HISTORY:

Appetite - decreased since 3 days

Bowel and bladder movements  - Regular

Sleep  - Adequate 

Diet - Mixed

GENERAL PHYSICAL EXAMINATION

Patient is conscious , coherent and cooperative well oriented to time , place and person

Pallor                       - Absent

  Icterus                     - Absent

  Cyanosis                  -Absent

  Clubbing                   -Absent

 Generalised Lymphadenopathy     - Absent

 Bilateral Pedal Edema     - Absent

VITALS: 

Temp: febrile
BP: 110/80 mmHg supine position
PR- 90 bpm
RR- 16cpm
 

SYSTEM EXAMINATION:

Abdominal examination- 

 INSPECTION

On Inspection Abdomen is flat,

 no abdominal distension, 

umbilicus is central and  inverted ,

no scars ,sinuses

PALPATION

All inspectory findings are confirmed

Tenderness present in epigastric region and right hypochondrium region

Tenderness present in right renal angle

Blanching present on  Abdomen and back

liver dullness  in 5th intercoastal space, 


PERCUSSION : No significant findings


AUSCULTATION: bowel sounds heard

 

RESPIRATORY EXAMINATION 

trachea central,

normal respiratory movements,

normal vesicular breath sounds.


CARDIOVASCULAR SYSTEM

S1 ,S2 heard ,no murmurs


CNS EXAMINATION 

 Normal


INVESTIGATIONS:

Fever chart 





CHEST X RAY







USG




ECG




PROVISIONAL DIAGNOSIS 
 Dengue fever (NS 1 positive)
?pyelonephritis ( USG)
? serositis 

TREATMENT

 29/11/22

1.IVF- NS/RL @75ml/hr
2.INJ PANTOP 40mg/IV/OD
3.TAB DOLO 650mg/PO/TID
4.TAB ZOFER 4mg/PO/SOS
5.INJ NEOMOL 100ml


30/11/22

1.IVF- NS/RL @75ml/hr
2.INJ PANTOP 40mg/IV/OD
3.TAB DOLO 650mg/PO/TID
4.TAB ZOFER 4mg/PO/SOS
5.INJ NEOMOL 100ml

1/12/22


1.IVF- NS/RL @70ml/hr
2.INJ PANTOP 40mg/IV/OD
3.TAB DOLO 650mg/PO/TID
4.TAB ZOFER 4mg/PO/SOS
5.INJ NEOMOL 100ml
6.INJ PIPTAZ 4.5g/IV/TID in 50ml NS dilution
Over 10mins
7.PLENTY OF ORAL FLUIDS

2/12/22

IVF- NS/RL @100ml/hr

2.INJ PANTOP 40mg/IV/OD

3.TAB DOLO 650mg/PO/TID

4.TAB ZOFER 4mg/PO/SOS

5.INJ NEOMOL1gm IV/SOS

6.PLENTY OF ORAL FLUIDS


3/12/22

1.IVF- NS/RL @100ml/hr

2.INJ PANTOP 40mg/IV/OD

3.TAB DOLO 650mg/PO/TID

4.TAB ZOFER 4mg/PO/SOS

5.PLENTY OF ORAL FLUIDS

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