58 year old male with fever

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 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 based inputs.


 CHIEF COMPLAINTS

58 year old male Pt came with the chief complaints of 

fever since 8 days

HOPI 

Pt was apparently asymptomatic 8 days back then had fever which was high grade associated with chills and rigors more during night time associated with cold cough, burning micturition, body pains, nausea, headache.

 No history of vomitings , loose stools, hematuria

PAST HISTORY 

K/C/O ASTHMA since 10 years( used medication for it but now not using)

N/K/C/O HTN , DM, TB, EPILEPSY, CAD

DAILY ROUTINE

wakes up at 5:00 does his daily routines and goes to farm and takes breakfast at 9:00 am and goes to work and takes lunch at 1: 00 pm and goes to work and returns home by 7: 00 and watches TV for some time and takes dinner by 9:00 pm and goes to bed by 10:00 

FAMILY HISTORY

His mother( expired 2 yrs ago)has htn and dm since 10 years

PERSONAL HISTORY 

Diet - mixed

Appetite- decreased

Bowel and bladder movements-regular

Sleep-adequate

Habits-used to consume alcohol 18 years back then he stopped consuming it and use to take 1 pack of cigars 5 years back but since 5 years he is taking 1 or 2 cigars per day


GENERAL EXAMINATION

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

moderately built and moderately nourished 

 Pallor-absent 

icterus- absent

cyanosis- absent

clubbing- absent

Lymphadenopathy - absent

Edema- absent






VITALS

BP- 110/80

PR-84

RR-24

TEMP- Afebrile 

SYSTEMIC EXAMINATION

CVS- S1 S2+

RS- BAE+

P/A- soft, non tender

CNS- Intact

INVESTIGATIONS

DAY-1











DAY -2






PROVISIONAL DIAGNOSIS 

Dengue NS1 positive


TREATMENT

1. IV fluids NS, RL @75ml/hr

2. INJ optineuron in 100ml NS IV OD over 30mins

3. INJ Neomal 1gm IV if Temp >101

4. Tab PAN 40mg PO OD

5.Tab hifenac MR PO OD



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