32YR OLD MALE WITH FEVER

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A 32YR OLD MALE CAME TO OPD 

WITH

CHIEF COMPLAINTS OF

 FEVER SINCE 4 days 

 LOOSE STOOLS SINCE YESTERDAY

HISTORY OF PRESENT ILLNESS :

PATIENT WAS APPARENT ASSYMPTOMATIC 4 DAYS  BACK THEN DEVELOPED 

FEVER WHICH WAS HIGH GRADE , INTERMITTENT AND DECREASED ON MEDICATION 

 LOOSE STOOLS 2 EPISODES YESTERDAY , WATERY ,NO MUCOUS/BLOOD

ASSOCIATED WITH GENERALISED WEAKNESS,BODY PAINS AND HEADACHE 

PATIENT HAS COLD 

PATIENT HAS COUGH ( NON PRODUCTIVE)

BITTER TASTE IN MOUTH 

DECREASED APPETITE

NO H/O PAIN ABDOMEN /VOMITING 

NO H/O GIDDINESS/LOC/BURNING MICTURITION

NO OTHER SYMPTOMS

PAST HISTORY:

K/C/O TYPE 2 DM SINCE 6 MONTHS AND IS ON MEDICATION 

T.METFORMIN 500MG OD

NO H/O HTN,

M,EPILEPSY,TB,ASTHMA

Personal history:

Consumes mixed diet

Appetite reduced since 2 days

Bowels regular 

Family history:

no significant family history 

GENERAL EXAMINATION:

PATIENT WAS CONCIOUS , COHERENT,COOPERATIVE AND WELL ORIENTED TO TIME AND PLACE 

VITALS 

BP: 100/70mmhg 

PR: 80bpm

SPO2 : 100% AT ROOM AIR 

TEMP: 96.0F

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,EDEMA,

GENERALISED LYMPHADENOPATHY 

SYSTEMIC EXAMINATION :

CVS:

S1S2 HEARD

NO THRILLS AND MURMURS

RESPIRATORY SYSTEM: 

NVBS +

BAE+

PER ABDOMEN :

ABDOMEN IS SOFT 

NON TENDER 

NO PALPABLE MASS 

INVESTIGATIONS :

1.HAEMOGRAM 

HB: 14.8gm/dl

TLC:6,400

PLATELETS:2,05,000

2.RBS 

234gm/dl

3.SERUM UREA :43mg/dl

4.SERUM CREAT :1.4mg/dl

5.SERUM URIC ACID : 7.4mg/dl

5.SERUM ELECTROLYTES

Na:137mEq/L

K:4.0mEq/L

Cl:97mEq/L

6.LFT

TOTAL BILIRUBIN :1.09

DIRECT BILIRUBIN :0.20

AST:29

ALT:31

ALP:91

A/G RATIO:1.39

7.RAPID DENGUE TEST

NS1: NEGATIVE

DIAGNOSIS : VIRAL PYREXIA UNDER EVALUATION

?VIRAL PNEUMONIA 

Treatment given:

1. IVF: NS, DNS & RL @100ml/hr continuous infusion

2. TAB. DOLO 650 MG QID

3. TAB.PAN 40mg OD

3. Inj. OPTINEURON 1 amp in 100 ml NS/IV/OD

4.Inj.PCM 1gm IV/STAT (if temp > 101F)

5. Temp charting and Tepid sponging 4ty hourly 

6.. BP/PR/spo2 MONITORING