A 40 year olds male with rickettsial fever
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
40yrs old male patient admitted on 18/10/21 with complaint of Insect bite , fever and headache since 15days and pain abdomen since 10days and loss of appetite since 1week . Blood in stools one episode in the morning.
History of present illness:
Patient Was apparently asymptomatic 15days back then he developed fever insidious onset, gradually progressive, diurnal variation of more during night and relieved on medication.
C/0 Pain abdomen more in left iliac fossa non radiating and not associated with nausea , vomiting.
C/o Headache diffuse type non radiating not associated with diminished or blurring of vision.
C/o Blood in stools since morning fresh blood not mixed in stools.
Past history :
He is not a known case of diabetes ,hypertension ,tuberculosis,epilepsy ,asthma
Personal history:
Diet :mixed
Appetite :normal
Sleep :adequate
Bowel and bladder: regular
Addictions:Daily drinks toddy 1litre
General examination:
Pallor:no
Icterus :No
Cyanosis :no
Clubbing :no
Lymphadenopathy :no
Vitals
Temperature :98.5
Pulse:110/min
Respiratory rate:20/min
Blood pressure :110/80mmhg
Cardiovascular examination :
Thrills: not heard
S1 and s2 heard
Respiratory examination:
Dysponea : absent
Wheeze:absent
Position of trachea : central
Breath sounds:vesicular
Abdomen examination:
Shape: scaphoid
Tenderness : absent
Palpable mass : absent
Hernial orifices : normal
Liver and spleen not palpable
Central nervous system examination :
Patient was conscious coherent and co operative and well oriented to time place and person
Level of consciousness- conscious
Speech- normal
Investigations:
Hemogram
HIV rapid test
Provisional diagnosis:
pyrexia under evaluation
Scrub typus positive .
Treatment (18/10/21):
Ivf ns,RL @100/ hrInj neomol l00ml / iv if fever > 101.01FInj pantop 40ml iv odInj Zofer 4mg iv sos Tab dolo650mg po TIDTabDOXYCYCLINE 100mg po bd Inj optineuron 1amp in 100ml ns iv Monitor vitals 4hrly .
Vitals(19/10/21):
3 episodes of spikes.
Pulse rate 89bpm ,Regular , normal volume.
Blood pressure 130/90 mm/Hg
Respiratory rate 20 cpm
GRBS: 140mg/dl
Temperature: 98.4F
Treatment (19/10/21):
Ivf ns,RL @100/ hrInj neomol l00ml / iv if fever > 101.01FInj pantop 40ml iv odInj Zofer 4mg iv sos Tab dolo650mg po TIDTabDOXYCYCLINE 100mg po bd Inj FALCIGO iv at 0, 12, 24,48.Inj optineuron 1amp in 100ml ns iv Monitor vitals 4hrly .
Vitals(20/10/21):
2 episodes of spikesHeadache ( diffuse type)
2 episodes of spikes
Headache ( diffuse type)
Pulse rate 72bpm ,Regular , normal volume.
Blood pressure 130/90 mm/Hg
Respiratory rate 24 cpm
Temperature: 98.6F
GRBS: 108mg/dl
Pulse rate 72bpm ,Regular , normal volume.
Blood pressure 130/90 mm/Hg
Respiratory rate 24 cpm
Temperature: 98.6F
GRBS: 108mg/dl
Treatment (20/10/21):
Ivf ns,RL @100/ hrInj neomol l00ml / iv if fever > 101.01FInj pantop 40ml iv odInj Zofer 4mg iv sos Tab dolo650mg po TIDTabDOXYCYCLINE 100mg po bd Inj FALCIGO iv at 0, 12, 24,48.Inj optineuron 1amp in 100ml ns iv Syp lactulose 10ml Inj ceftriaxone iv Monitor vitals 4hrly .
Vitals(21/10/21):
1 episodes of spikes
Headache
Pulse rate 76bpm ,Regular , normal volume.
Blood pressure 100/70 mm/Hg
Respiratory rate 22cpm
Temperature: 98.6F
GRBS: 107mg/dl
Pulse rate 76bpm ,Regular , normal volume.
Blood pressure 100/70 mm/Hg
Respiratory rate 22cpm
Temperature: 98.6F
GRBS: 107mg/dl
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