36 Year old Male with high grade fever, loose stools and cough since 3 days

 RACHANA GANGULA 

INTERN 


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-centred online learning portfolio and your valuable comments on comment box is welcome. 

36 year old Male with high grade fever, loose stools and cough since 3 days


36 year old male who is a fish seller by occupation came with the chief complaints fever since 3 days, loose stools since 3 days and cough since 1 month. 

Patient was apparently asymptomatic 1 month back when he developed cough which was productive- non foul smelling, non blood stained, colour- brownish/ whitish , quantity- spoonful per day. No aggravating or relieving factors. It increased in intensity 3 days back with the onset of his fever. 

He developed fever 3 days back which was high grade, associated with chills and rigor, continuous fever ,  relieved on medication.

Loose stools since 3 days- watery, non blood stained. Around 10 episodes per day

H/O Travel to forest area 10 days back. 

 No h/o pain abdomen, vomitings, jaundice, 


Past history


N/k/C/o HTN, DM,epilepsy,asthma thyroid,CVA. 

H/O appendicectomy done 5 years back 



Personal history 

Sleep- adequate 

Bowel and bladder- loose stool since 3 days 10 episodes 

Diet - mixed 

Appetite- decreased since 3 days 

Addictions- 

Regular Alcohol intake (180 ml whiskey daily) for 10 years. Stopped 1 month ago. 

Smokes 1 pack of cigarettes/ day since 10 years. 


General examination- 

Temp - 105F (at time of admission) 

PR- 138 bpm 

RR- 24 cpm 

BP- 100/70 mmhg 

GRBS- 148 mg/dl


No pallor, icterus, cyanosis, lymphadenopathy, Edema

SUBCONJUNCTIVAL HEMORRAGE + 

Right eye- 







Left eye- 


CLINICAL IMAGES- 




Systemic examination 

P/a: 

No sinuses

Surgical Scar in right iliac fossa (h/o appendicectomy) 

soft, Tenderness present in right hypochondriac, right lumbar and right iliac fossa 

Bowel sounds + 



Cvs:S1S2 heard ,no murmers

CNS: NFND

R/S- BAE,NVBS heard


Provisional Diagnosis 


Pyrexia of thrombocytopenia under evaluation

? Leptospirosis

 with cholelithiasis with chronic bronchitis 



CHEST X RAY 


ECG




    








    







UPDATED FEVER CHART OF PATIENT WITH LABORATORY INVESTIGATION DURING HOSPITAL STAY 





SOAP NOTES DURING HOSPITAL STAY- 


19/05/2023

ICU BED 2 36/M


DR.RAKESH BISWAS(HOD)

DR.ZAIN(SR)

DR.PAVAN(PGY2)

DR.AJAY KUMAR(PGY1)


S:

Fever spike of 100.1 at 12 am 

Stools passed


O:

ON EXAMINATION:

CONCIOUS COHERENT AND COOPERATIVE 

BP:100/70mmHg

PR:94BPM

RR:23cpm

Spo2 :98% on RA



CVS:S1,S2 HEARD ,NO MURMURS

RS:BAE+,NVBS, NO ADDED SOUNDS

CNS:- NAD 

P/A- soft, tenderness in epigastric region 

Bowel sounds heard 



A:-

Pyrexia of thrombocytopenia under evaluation

? Leptospirosis

 with cholelithiasis with chronic bronchitis 


P:-

1)IV FLUIDS NS @ 75 ml/hr

2)INJ. DOXYCYCLINE 100 mg/ IV/BD [D3]

3)INJ. PANTOP 40mg IV/OD 

4)TAB. DOLO 650mg PO/ SOS 

5)MONITOR VITALS & INFORM SOS


20/05/2023

ICU BED 2 36/M


DR.RAKESH BISWAS(HOD)

DR.ZAIN(SR)

DR.PAVAN(PGY2)

DR.AJAY KUMAR(PGY1)


S:

Fever spike of 102.4 yesterday night at 9pm 

Stools passed 



O:

ON EXAMINATION:

CONCIOUS COHERENT AND COOPERATIVE 

BP:110/60mmHg

PR:94BPM

RR:26cpm

Spo2 :96% on RA



CVS:S1,S2 HEARD ,NO MURMURS

RS:BAE+,NVBS, NO ADDED SOUNDS

CNS:- NAD 

P/A- soft, tenderness in epigastric region 

Bowel sounds heard 



A:-

Pyrexia of thrombocytopenia with leukopenia under evaluation

? Leptospirosis

with cholelithiasis with chronic bronchitis 


P:-

1)IV FLUIDS NS @ 75 ml/hr

2)INJ. DOXYCYCLINE 100 mg/ IV/BD [D4]

3)INJ. PANTOP 40mg IV/OD 

4)TAB. DOLO 650mg PO/ SOS 

5)MONITOR VITALS & INFORM SOS


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