19 Year old male with fever and lower backache

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CHIEF COMPLAINT

patient came to OPD with a chief complaint of Fever since 3 days ,Lower back ache since 3 days,Generalized weakness since 3 days


HISTORY  OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 10 days back then he developed high grade fever which was continuous ,no diurnal variation which got relieved on medication given by local RMP [some IV medication was given for 1 day and oral medication for 3 days].

Now again since 3 days he had high grade fever which was continuous not associated with chills and rigor ,no diurnal variation

He had one episode of vomiting today i.e 30 Nov 2022 which was non projectile contained food particles

He also complained of low back ache since 3 days which is insidious in onset ,gradually progressive, and is persistent and pain increased during inspiration and no relieving factors.[he was unable to describe the character of pain]

He also complained of abdominal pain which is insidious in onset persistent not associated with nausea and vomiting

He also complained of generalized weakness since 3 days 

No history of burning micturition, increased frequency of urine ,difficulty to pass urine ,nocturnal eneursis

No history of loose stools 


DAILY ROUTINE 

He wakes up at 8 AM and does his morning routine , eats breakfast at 9 AM usually eats 4 idlies or 1 dosa or 4 bondas and goes to college at 9 AM by bus as his college is 20-25 km far from his home ,He is a CEC student attends all his classes and eat lunch at 2PM usually he eats junk foods [fried rice ,noodles,road side foods] almost daily as he feels embarrassed taking lunch box along with him , college ends at 4 PM ,comes back to home by 5 PM and eat dinner at 6 PM ,he usually prefers to eat rice in dinner. After having dinner he watches movies till 12 AM or go out with friends

His parents are agricultural labourer so sometimes he goes along with them Or sometimes he skips college and goes to work along with his cousin brother as part of recreation [ his cousin brother has plastic and iron shop where they store all the plastic and iron which they collected and sell them to others for reuse]

Since 1 month he stopped going to college as his other friends in their village were not going


PAST HISTORY 

History of fever 10 days back which was diagnosed as typhoid and was given oral medication for 3 days and iv medication for 1 day

No history of Hypertension, diabetes, asthma, epilepsy,TB

No history of prolonged hospital stay

No history of previous surgeries


FAMILY HISTORY 

His brother alao had similar History of fever which was diagnosed and treated by local RMP

His brother is in 4 standard and stays in hostel and he came home with fever 15 days ago patient developed fever after his brother symptoms subsided 


PERSONAL HISTORY 

Diet : mixed 

Appetite: decreased since 3 days

Bowel and bladder:regular 

Sleep:adequate

History of toddy and beer consumption occasionally 


TREATMENT HISTORY 

Used DOLO 650 mg tid for 3 days


GENERAL EXAMINATION 

Patient was conscious,coherent  cooperative

Moderately build and moderately nourished

well oriented to time ,place and person


Pallor : no pallor,Lower palpebral congestion is seen
Icterus: absent
clubbing: absent
cyanosis: absent
Lymphadenopathy: absent
Edema : absent











VITALS
Temp: febrile
BP: 110/80 mmHg supine position
PR- 90 bpm
RR- 16cpm
 

SYSTEM EXAMINATION:

Abdominal examination- 

 INSPECTION

On Inspection Abdomen is flat, no abdominal distension, umbilicus is central and  inverted ,no engorged veins,no scars,sinuses,hernial ornifices are clear

PALPATION

All inspectory findings are confirmed

Tenderness present in epigastric region and right hypochondrium region

Tenderness present in right renal angle

Blanching present on  Abdomen and back

liver dullness  in 5th intercoastal space, 








PERCUSSION : No significant findings


AUSCULTATION: bowel sounds heard

 

RESPIRATORY EXAMINATION 

trachea central,

normal respiratory movements,

normal vesicular breath sounds.


CARDIOVASCULAR SYSTEM

S1 ,S2 heard ,no murmurs


CNS EXAMINATION

CNS examination

No focal neurological deficits


INVESTIGATIONS 

FEVER CHART



CHEST X-RAY


Date 29 Nov 2022







                           NS 1 antigen


USG


Review USG on 30 Nov 2022



ECHO






PROVISIONAL DIAGNOSIS 
 Dengue fever (NS 1 positive)
?pyelonephritis ( USG)
? serositis 

TREATMENT

 On 29 Nov 2022

1.IVF- NS/RL @75ml/hr
2.INJ PANTOP 40mg/IV/OD
3.TAB DOLO 650mg/PO/TID
4.TAB ZOFER 4mg/PO/SOS
5.INJ NEOMOL 100ml


On 30 Nov 2022

1.IVF- NS/RL @75ml/hr
2.INJ PANTOP 40mg/IV/OD
3.TAB DOLO 650mg/PO/TID
4.TAB ZOFER 4mg/PO/SOS
5.INJ NEOMOL 100ml




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