28 year old man with fever loose stools and vomitings

Medical case discussion 

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        CASE DISCUSSION

C/o Fever since 4 days High grade , associated with chills and rigor , intermittent type, temporarily relieved on medication 

Loose stools since 4 days 3-4 episodes/day ,watery consistency ,non -mucous, non blood stained , large volume 

Vomitings since 3 days 5 to 6 episodes/day with food particles as content , non billions, non foul smelling 

No history of outside food intake 

No C/o cold , cough , pain abdomen , burning micturition, shortness of breath 

Not a k/c/o HTN , DM , CVA , CAD , TB , Asthma

Alcohol intake 90 ml twice weekly since past 10 years 

Smoking occasional (1 or 2 cigarettes)

GENERAL EXAMINATION

  •Patient is examined in a well lit room after obtaining consent

•Patient is conscious, coherent, cooperative.

 Well built and well nourished.



•No Pallor,Icterus,clubbing, cyanosis, koilonychia, edema are absent


•VITALS 

Temp 102°F
PR 83 bpm
BP 110/80
RR  21 cpm
SpO2 98
GRBS 119mg/dl



              SYSTEMIC EXAMINATION 



RS- bilateral air entry present 


CVS : S1, S2 + no murmurs 


P/A- soft and non tender



CNS : No focal neurological defeicit 

HMF intact 

Power in B/L upper and lower limb Is 5

Reflexes are present with B/L plantars and flexors

Diagnosis: 

Viral pyrexia under evaluation 

? Dengue

Investigations: 

M.p.strip test - negative

Treatment:

Tab.Dolo 650mg/po/TID

Inj optineuronp(1 ampule) in 100 ml NS

Inj Neomol 1Gm IV -SOS (when Temp is >101°F)

Tab Sporolac PO/TID

Monitor vitals every 4th hourly