25 M with fever and generalised weakness

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 box is welcome.

CHIEF COMPLAINTS:-
Patient came to casuality with c/o Fever since 3 days
HISTORY OF PRESENT ILLNESS:-
Patient was apparently normal 3 days back, he then developed fever which is high grade, intermittent, associated with chills and rigor with evening rise of temperature
Fever associated with headache, generalised body pains and generalised weakness
Pt c/o burning sensation of eyes, loss of apetite
SOB on exertion(grade 2) since 3 days 
No c/o cold, cough, pain abdomen, burning micturition, vomitings, loose stools, chest pain. 
PAST HISTORY:-
Not a k/c/o DM, HTN, TB, Epilepsy, CVA, CAD, Asthma, Thyroid disorders. 
PERSONAL HISTORY:-
Diet - Mixed
Appetite - lost since 3 days
Bowel & Bladder - Regular
Sleep - Regular
Addictions - No
Known Allergies-No
FAMILY HISTORY:-
Insignificant
GENERAL EXAMINATION:-
Patient is conscious , coherent & co-operative
Well built and nourished.
No signs of pallor,icterus, clubbing, cyanosis, pedal edema and lymphadenopathy.

Vitals @ admission 
Temp - 98.7F
RR -17CPM
PR - 104BPM
BP - 130/90mmHg
Spo2 - 99% RA
GRBS-137 mg%
SYSTEMIC EXAMINATION:-
Respiratory system:-
BAE present, NVBS heard
Dyspnoea on exertion Grade-II
No wheeze and added sounds
Cardiovascular system:-
S1, S2 heard
No murmurs and thrills
Abdomen:-
Obese
Soft and Non tender 
No organomegaly
CNS:-
NFND
PROVISIONAL DIAGNOSIS:-
Viral pyrexia secondary to Dengue NS1 positive. 
Clinical Images:-

Investigations:

TREATMENT:-
1)IV fluids NS, RL @ 100ml/hr
2) Inj. Optineuron 10amp in 100ml NS/IV/OD
3) Tab. PAN 40mg PO/OD
4)Tab.Dolo 650mg PO/BD
5)Inj.Neomol 1g/IV/SOS(If temp >101°F) 
6)Temp monitoring 4th hrly
7) Vitals monitoring 4th hrly

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