Friday 4 March 2022

40 year old male presenting with fever and headache

 This is an 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 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 inputs on the comment box. 


Chief complaints

>fever since 3 days
>headache since 2 days


History of presenting Illness
Patient was apparently asymptomatic 3 days ago then developed fever, high grade a/w chills, not associated with diurnal variation, relieving on medication
H/O headache present since 2 days in frontal region, continuous, 
No H/O vomiting, loose stools
No H/O nausea, abdominal distension
No H/O rash, chough, cold
No H/O burning mituration, dysurea

Past H/O
Not a K/C/O DM, HTN, thyroid disease, BA

PERSONAL HISTORY :

DIET - MIXED
APPETITE -NORMAL ,
BOWEL MOVEMENT - REGULAR , 
BLADDER MOVEMENTS - REGULAR, 
ALCOHOL ADDICTION, LAST BINGE 3 DAYS BACK 60 ML WHISKY

FAMILY HISTORY - 
NAD

ON EXAMINATION -

PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA

VITALS - 

TEMPERATURE - 99.1
PULSE RATE - 84 BPM
BLOOD PRESSURE - 110/70 MM OF HG 
RESPIRATORY RATE - 16
SPO2 - 99 % AT ROOM AIR

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD

Investigations

ECG
                                      Normal sinus rhythm


Chest X-ray


CUE (2/3/22)

Albumin: +
Sugar: ++++
Pus cells: 4-5
Epithelial cells: 3-4 

HEMOGRAM
HB 14.3
TC 2800
PLT 92000
MCV 80.2
PCV 41.2
MCH 27.5
MCH 34.3
SMEAR - NORMOCYTIC NORMOCHROMIC, WITH BICYTOPENIA
SMEAR FOR MALARIAL PARASITE - Negative

BGT - O +ve

CUE
ALB - trace
Sugar - nil
Puscells - 2-4
Epithelial cells - 2-4

HbSAg - negative
HCV - negative
HIV - negative

Dengue serology
NS1 - +ve
IgG - negative
IgM - negative

RFT
Urea- 22
Creatinine-0.9
UA-4.1
Calcium-9.2
Phosphorus-2.5
Sodium-136
Potassium-3.8
Chloride-102

LFT
TB-1.37
DB-0.47
AST-84
ALT-49
ALP-168
TP-56
ALB-3.31


Diagnosis
Viral pyrexia


Treatment
Inj. Paracetamol 1g IV Stat
IVF  NS/RL at 75ml/hr
T. Paracetamol 650mg PO TID


Day 1


Day 2 SOAP NOTES

3/3/22

S-C/o headache, neck pain subsided, one fever spikes today

O-
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA

VITALS - 

TEMPERATURE - 98.1
PULSE RATE - 75 BPM
BLOOD PRESSURE - 120/80 MM OF HG 
RESPIRATORY RATE - 17
SPO2 - 100 % AT ROOM AIR

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD

HEMOGRAM
HB 16
TLC 3000
PCV 46.6
MCV 82.9
MCH 28.9
MCHC 34.2
Plt 90,000
P. S normocytic, normochromic with bicytopenia

A-
viral pyrexia with thrombocytopenia with NS1 POSITIVE


P-
Inj. Optineuron in 100ml NS over 30 mins
IVF NS/RL at 150ml/hr
T. Paracetamol 650mg PO TID



SOAP NOTES DAY 3

4/3/22

S-C/o headache,neck pain subsided, no fever spikes today

O-
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA, no petichiae


VITALS - 

TEMPERATURE - 98.3
PULSE RATE - 82 BPM
BLOOD PRESSURE - 
110/70 MM OF HG supine
110/70 mmHg standing
RESPIRATORY RATE - 19
SPO2 - 99 % AT ROOM AIR

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD

HEMOGRAM
HB 15.9
TLC 2300
PCV 46.3
MCV 82.9 
Plt 50,000
P. S NORMOCYTIC NORMOCHROMIC WITH neutropenia and thrombocytopenia

A-
viral pyrexia with thrombocytopenia with NS1 POSITIVE


P-
Inj. Optineuron in 100ml NS over 30 mins
IVF NS/RL at 150ml/hr
T. Paracetamol 650mg PO TID


SOAP NOTES DAY 4

5/3/22

S-C/o headache,neck pain subsided, no fever spikes today

O-
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA, no petichiae


VITALS - 

TEMPERATURE - 96.9
PULSE RATE - 85 BPM
BLOOD PRESSURE - 
110/70 MM OF HG supine
110/70 mmHg standing
RESPIRATORY RATE - 19
SPO2 - 98 % AT ROOM AIR

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD

HEMOGRAM
HB 15.1
TLC 2900
PCV 45.2
MCV 80.9 
Plt 41,000
P. S NORMOCYTIC NORMOCHROMIC WITH neutropenia and thrombocytopenia

Platlet count
Day 1 - 92,000
Day 2 - 90,000
Day 3 - 50,000
Day 4 - 41,000

A-
viral pyrexia with thrombocytopenia with NS1 POSITIVE


P-
Inj. Optineuron in 100ml NS over 30 mins
IVF NS/RL at 150ml/hr
T. Paracetamol 650mg PO TID



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