A 40/M with fever and headache CBBLE UDHC similar cases
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Normal sinus rhythm
Chief complaints
Complaints of fever since 3 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
Chest X-ray
CUE (2/3/22)
Albumin: trace
Sugar: nil
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
AMC
Day 2
3/3/22
40 year /male
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
AMC
Day 3
4/3/22
40 year /male
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
http://venkata-phaneendra.blogspot.com/2022/03/a-40m-with-fever-and-headache-cbble.html
WARD
Day 4
5/3/22
40 year /male
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
WARD
Day 5
5/3/22
40 year /male
S- no new complaints, no fever spikes today
O-
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA, no petichiae
VITALS -
TEMPERATURE - 97.5
PULSE RATE - 75 BPM
BLOOD PRESSURE -
110/70 MM OF HG supine
110/70 mmHg standing
RESPIRATORY RATE - 15
SPO2 - 99 % AT ROOM AIR
SYSTEMIC EXAMINATION -
PA : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CVS : S1 AND S2 HEARD , NO MURMURS
RS : BILATERAL AIR ENTRY PRESENT ,NVBS
CNS : NAD
HEMOGRAM
HB 15.6
TLC 9,500
PCV 48.6
MCV 82.4
Plt 80,000
P. S NORMOCYTIC NORMOCHROMIC, with thrombocytopenia
Platlet count
Day 1 - 92,000
Day 2 - 90,000
Day 3 - 50,000
Day 4 - 41,000
Day 5 - 80,000
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
WARD
Day 6
7/3/22
40 year /male
S- no new complaints, no fever spikes today
O-
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA, no petichiae
VITALS -
TEMPERATURE - 97.4
PULSE RATE - 85 BPM
BLOOD PRESSURE -
110/70 MM OF HG supine
110/70 mmHg standing
RESPIRATORY RATE - 19
SPO2 - 99 % AT ROOM AIR
SYSTEMIC EXAMINATION -
PA : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CVS : S1 AND S2 HEARD , NO MURMURS
RS : BILATERAL AIR ENTRY PRESENT ,NVBS
CNS : NAD
HEMOGRAM
HB 16.2
TLC 6,350
PCV 47.6
MCV 82.6
Plt 80,000
P. S NORMOCYTIC NORMOCHROMIC, with thrombocytopenia
Platlet count
Day 1 - 92,000
Day 2 - 90,000
Day 3 - 50,000
Day 4 - 41,000
Day 5 - 80,000
Day 6 - 80,000
A-
viral pyrexia with thrombocytopenia with NS1 POSITIVE
P-
Plenty of oral fluids
T. Paracetamol 650mg PO SOS
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