A 18 YEAR OLD MALE WITH FEVER AND BODY PAINS.

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

A 18 YEAR OLD MALE WITH FEVER AND BODY PAINS.


A 18year old male came  to casualty with chief complaints of 
fever since 2days. C/o lower back pain since 2days.c/o general bodypains since 2days.


Patient was apparently asymptomatic 2days back then he developed fever which is of insidious in onset, intermittent and is of high grade fever,a/w chills and relieved on medication a/w head ache.
No h/o any burning micturition,throat pain,cold,cough.
No h/o pedal edema, decreased urine outfit,palpitations,chest pain.

PAST HISTORY:
Not a k/c/o HTN,DM, CAD, asthma, TB, epilepsy.


PERSONAL HISTORY:
Patient has mixed diet with normal appetite and adequate sleep. 
he has normal bowel movements and bladder filling. 
No addictions. 

No significant family history or allergic history. 

GENERAL EXAMNATION:
Patient is c/c/c with moderate built and moderate nourishment. 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema. 
VITALS:
BP: 80/60 MMHG, 
PR: 98bpm 
Temp: 98.2°F, 
RR: 19 CPM, 
SPO2: 99% 

RS: BAE+,NVBS

CVS: S1 ans S2 heard. No murmurs. 
P/A: soft and non-tender. 
CNS: No focal neurological deficits.

INVESTIGATIONS:
1) HEMOGRAM : 
Hb: 13.3
TLC: 10500
N:92
L:6
PCV: 38.4
Mcv:76
MCH:26
MCHC:34.6
Rbc-5.05
Plc-2.77

2) LFT:
TB: 1.01
DB: 0.20
SGOT: 18
SGPT: 10
ALP: 296
TP: 5.9
A: 2.9
A/G: 0.99

3)CUE
Alb:nill
Sug:nill
Ec:2-3
Pc:2-3
RBC:nill



4)serum creatinine-1.0

 5)serum electrolytes
Na+:139
K+:3.8
Cl-:98
   
6)blood for MP Strip test :-ve

CXR-

Fever charting-
Blood urea-34

Serology and dengue- negative.

PROVISIONAL DIAGNOSIS:VIRAL PYREXIA UNDER EVALUATION

Treatment given-
IV fluids- NS,RL @100 ml/hr
Inj.pan 40 mg IV od
Inj.optineuron 1 amp in 100 ml NS IV od
Tab.ultracet 1/2 tab po qid
Strict temperature monitoring 4th hourly
Strict bp,pr monitoring 4th hourly.

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