19 year old male with fever and lower back pain
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This is a case of 19 year old male resident of mirylaguda who is an Intermediate second year student came to general medicine OPD with chief complaints of :
Fever since 7 days.
Lower back pain since 7 days.
Abdominal pain since 7 days.
Generalized weakness since 7 days.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 17 days back then he developed high grade fever which was continuous, no diurnal variation which got relieved on medication given by local RMP (IV medication for 1 day and oral medication for 3 days).
Now again since 7 days he had high grade fever which was continuous not associated with chills, rigor and no diurnal variation.
He had one episode of vomiting 7days back(30 November) which was non projectile and contained food particles.
He also complained of low back pain since 7 days which is insidious in onset, gradually progressive, which is persistent and pain increased during inspiration and no relieving factors.
He also complained of abdominal pain since 7 days which is insidious in onset persistent not associated with nausea and vomiting.
He also complained of generalized weakness since 7 days.
No history of :
Increased frequency of urine.
Difficulty to pass urine.
Burning micturition.
Nocturnal eneursis.
No history of loose stools.
DAILY ROUTINE:
He wakes up at 8:00AM and does his morning routine, eats breakfast at 8:30AM. He usually eats 4 idlies or 1 dosa or 4 bondas and goes to college at 9:00AM by bus as his college is 25km far from his home.
He is a CEC student. He attends all his classes and eats lunch at 2:00PM. He usually eats junk food almost daily as he feels embarressed taking lunch box to college. College ends at 4:00PM ,comes back to home by 5:00PM and eat dinner at 7:00PM ,he usually prefers to eat rice in dinner.
After having dinner he watches movies till 12:00AM or go out with friends.
He stopped going to college sinec 1 month as his friends in his village stopped going.
PAST HISTORY:
No history of Hypertension, Diabetes, Asthma, Epilepsy, TB.
No history of prolonged hospital stay.
No history of previous surgeries.
PERSONAL HISTORY:
Diet : Mixed.
Appetite: Decreased since 7 days.
Bowel and bladder: Regular.
Sleep: Adequate.
Addictions: History of toddy and beer consumption occasionally.
TREATMENT HISTORY:
Used DOLO 650 mg tid for 7 days.
GENERAL EXAMINATION
Patient was conscious,coherent and cooperative
Moderately build and moderately nourished
well oriented to time, place and person.
Pallor : no pallor,Lower palpebral congestion is seen
Icterus: absent.
SYSTEM EXAMINATION:
ABDOMINAL EXAMINATION:
INSPECTION:
On Inspection Abdomen is flat, with no abdominal distension, umbilicus is central and inverted,no engorged veins, no scars, sinuses,hernial orifices are clear.
PALPATION:
All inspectory findings are confirmed.
Tenderness present in the epigastric region and right hypochondrium region.
Tenderness present in the right renal angle.
PERCUSSION : No significant findings.
AUSCULTATION: bowel sounds heard.
RESPIRATORY SYSTEM EXAMINATION:
Trachea: central, normal respiratory movements,
normal vesicular breath sounds are heard.
CARDIOVASCULAR SYSTEM:
S1 ,S2 heard ,no murmurs heard.
CNS EXAMINATION:
No focal neurological deficits.
PROVISIONAL DIAGNOSIS: DENGUE FEVER
INVESTIGATIONS
FEVER CHART
x ray:
SERUM ELECTROLYTES:
HAEMOGRAM:
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