40/ M with fever and headache CBBLE UDHC similar case came to OPD Complaints of fever since 3 days

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Chief complaint    
 A 40/ M with fever and headache CBBLE UDHC similar case came to OPD 
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
Normal sinus rhythm

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
Normal sinus rhythm

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



Day 2 SOAP NOTES

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 COOPERATIVENO 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


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