19 yr old boy with Pyrexia

 Agust 2,2023


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 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.



 A 19year old male came to the opd with complains of fever since 30 days.C/O SOB since 15 to 20 days



HOPI:

 

Patient was apparently asymptomatic 1 month ago then he developed lowgrade intermittent  type of fever which aggravated since 15 days, mainly during the night time,temporarily relieved on medication.It was associated with bodypains and headache, low backache.Not associated with cold and cough, burning micturition and rash on  body.He complains of SOB  since 15 days which is present even on rest,which aggravates after having food.Bloating and chesttightness are present.

Cold is present since 3months after drinking softdrinks/colditems.





PAST HISTORY

N/K/C/O DM, TB, epilepsy, CVA, CAD, thyroid disorders and bronchial asthma.


FAMILY HISTORY:

Not significant


PERSONAL HISTORY: 


Diet :Mixed

Apetite:Normal

Bowel and bladder Movements:Regular

Sleep:Adequate

No  allergies and addictions

Daily routine: Patient wakes up at 7AM and has some breakfast at 8:30AM  and goes to college at 9AM.He skips his lunch.He comes back from college at 5 PM and eats some food at 6:30PM.He goes to play till 8pm.He skips dinner.He studies till 10pm for 2 hours.He sleeps by 11am.

He goes to college regularly despite his fever but 15 days back he could not eat properly due to   SOB while eating.

His dailyroutine is not changed due to his symptoms.


GENERAL EXAMINATION:

On examination patient is conscious, coherent, cooperative 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema 

VITALS:

Temp-Afebrile

PR-64bpm 

RR: 22Cpm 

BP:110/70mm Hg 

Spo2:99% at room air 

GRBS charting: 98mg/dL


Systemic examination:

Per abdomen:

Soft,Nontender

RS:

bilateral air entry is present.

Normal vesicular breath sounds are heard.

CVS:

S1S2 heard.No murmurs

CNS: 

HMF+,NFND


Provisional Diagnosis:

Viral pyrexia  under evaluation.

PUO?


Investigations:

Hemogram:




CUE:






LFT:



Peripheral smear:



Reticulocyte count



RFT:



ECG:



Chestxray:



Serology -ve

BGT B+ve

RBS 79mg/dl

Widal test -ve

Rapid dengue -ve

MP strip test negative


Clinical images:









TREATMENT

TAB PARACETAMOL 650 mg /PO/TID

MONITOR VITALS 4TH HRLY

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