25yr male with 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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever.

PRESENTING COMPLAINTS:

C/O fever since 5days

Cold since 3days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5days back and he developed fever, high grade, intermittent type, releives on taking medication 

Associated with cold since 2days.

Associated with epigastric pain since 2days

Associated with body pains since 1day.

No H/O cough, headache, vomitings, burning micturation.

HISTORY OF PAST ILLNESS:

Not k/c/o DM, HTN, TB, Epilepsy, CAD, Asthma 

PERSONAL HISTORY:

Diet- Mixed

Appetite- Decreased 

Sleep- Adequate 

Bowel and bladder movements- Regular 

Addictions:

Alcohol-drinks occasionally 

Tobacco- no

No known allergies 

FAMILY HISTORY:

No significant family history.

GENERAL EXAMINATION:

. The patient is conscious,  coherent, cooperative 

. Well nourished and well built 

. No pallor, icterus, cyanosis, clubbing, lymphadenopathy, Pedal edema.

Vitals:

Temperature- 99F

BP: 120/80 mmhg

Pulse rate: 78 bpm 

Respiratory rate: 16cpm 

SpO2: 98%

GRBS: 108 mg/dl@ admission 

Per Abdomen:

Inspection:- no scars seen.

Palpation:- tenderness in epigastric region.

Percussion:- No free fluid.

Auscultation:- Bowel sounds heard.

SYSTEMIC EXAMINATION:

CVS:

S1 S2 heard 

No cardiac Murmurs

Respiratory system :

No dyspnea 

No wheeze

Trachea position -Central 

Breath sounds -vesicular 

CNS:

No focal and neurological deficits

HMF -Normal

Pupils- Bilateral PSNL

                      Upper limb                        Lower limb

               Right             Left                  Right          Left

Tone:      Normal        Normal            Normal      Normal

Power:           5/5           5/5                   5/5              5/5

Reflexes:         Right             Left

Biceps              +                    +

Triceps            +                     +

Supinator         +                    +

Knee                +                   +

Ankle               +                  +

Plantar         Flexion        Flexion

LAB INVESTIGATIONS:

Peripheral smear:

PROVISIONAL DIAGNOSIS:

Dengue Fever (NS1 positive)

TREATMENT:

IV fluids (NS,RL @100ml/hr)

INJ. NEOMOL 1g IV/SOS

Tab. DOLO 650mg PO/TID

Tab. PAN 40mg PO/OD