A 32 year old male with fever and headache

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed.

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my cmpetancy i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

A. Vishal 

Roll no :-148


CASE PRESENTATION

A 32yr old male, who is a farmer presented to casuality on 29thmarch2022 with

CHEIF COMPLAINTS of

Fever since 1week

Headache since 5days

Generalised weakness and joint pains since 5days

HISTORY OF PRESENT ILLNESS:


Patient was apparently asymptomatic till 1week ago 
Later he developed fever insidious in onset and is of continuous type ,moderate to high grade not associated with chills and rigor visited local rmp and mild relief with medication 

history of headache and generalised weakness ,jointpains since 5days

 h/o vomitings 1episode noprojectile,nonbilious,food particles as content.
No h/o cough,sputum
No h/o burning micturition,stomach pain,loose stools
No h/o bleeding manifestation,
No h/o sob,pedal edema

PAST HISTORY 

Not a K/c/o  DM , HTN , asthma , epilepsy , TB ,CAD.

No past surgical history 


PERSONAL HISTORY 

Sleep-decreased

Appetite - decreased

Diet - mixed

Bowel and bladder movements - bowel movements are regular 

Addictions - no addictions


FAMILY HISTORY

No significant family history .


GENERAL EXAMINATION :

Patient is conscious ,  coherant ,cooperative

No pallor,icterus , cyanosis , lymphadenopathy, edema 

On Examination

VITALS-

Temp:febrile

Bp:110/70 mm hg 

PR ; 84bpm regular

RR:21/min

Cvs : s1 s2 +

Rs : BAE +

P/A: soft , tender


INVESTIGATION:-


Treatment :-

1) Ivf Ns/RL 100ml/hr
2) Inj. Pantop 40mg Iv OD
3) Inj. Zofer 4mg Iv BD
4) Inj. Neomol 1gm Iv sos
5) Tab. Dolo 650 po qid
6) Tab. Ultracet po BD
7) Temp. Charting 4thhrly

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