A 70 year male with fever and lower limb pain & weakness

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This is an online E - log book to discuss our patients 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-centered online portfolio and your valuable inputs on the comment box.


A 70 year male farmer by occupation came to opd with chief complaints of fever since 15 days, pain of both lower limbs since 10 days


Chief complaints:

Fever since 15 days

Pain of B/L lower limbs since 10 days


History of present illness:

Patient was apparently asymptomatic 15 days back. He developed fever which is high grade, continuous, with chills and rigors 15 days ago and is associated with pain of bilateral lower limbs since 10 days.

No h/o of cold, cough

No h/o of burning micturition

No h/o vomitings

No h/o loose motions

No h/o rash

No h/o hematuria

No h/o bleeding from gums

No h/o malina


History of past illness:

Is not a known case of HTN/DM/CAD/EPILEPSY


Personal history:

Married

Farmer by occupation

Appetite normal

Non vegetarian

Regular bowel and bladder movements

No allergies

Occasional alcohol intake


Family history:

Not significant

Immunisation status: up to the mark


General examination:

Pallor - no

No cyanosis, icterus

No lymphadenopathy, clubbing of fingers/toes, no oedema of feet, no malnutrition and dehydration


Vitals:

PR: 82 bpm

RR: 26 cycles per min

BP: 120/80 mm of hg

Temp: 98.6 F

GRBS: 102 mg/dl

SpO2: 98%


Systemic examination:

A. Cardiovascular system :


• S1, S2 are heard
• No thrills and no cardiac murmurs

B. Respiratory system:

• No dyspnoea, no wheezing
• Position of trachea - central
• Breath sounds - Vesicular

C. Per Abdominal Examination:

Shape of abdomen - scaphoid
• No Tenderness 
• No palpable mass , free fluids, bruits
• Liver, spleen not palpable
• there are no Bowel sounds

D. Central Nervous :

Patients is conscious, coherent, cooperative and well oriented to time and space

Speech normal

No signs of meningeal irritation

Cranial nerves - intact

Sensory system - intact

Glassgow scale - normal

Tone:  normal on both sides

Power: 

                               RT.                               LEFT

POWER    UL.             LL.                 UL.               LL

                  5/5.            3/5.                  5/5.              3/5


Reflexes:

               Biceps.       Triceps.       Supinator.      Knees.       Ankle

R.            ++              +                   +                  +                +

L.            ++               +                 ++                  +               +



Provisional diagnosis:

Viral Pyrexia with thrombocytopenia


Treatment:

IVF 1 NS, 1 RL , 1DNS@ 75 ml/ hr
2) INJ CEFTRIAXONE 1gm IV BD
3)INJ NEOMOL 1gm IV / SOS( if temp >101°F)
4) INJ ZOFER 4mg sos
5) TAB PCM 650 mg PO TID
6) TAB PAN 40 mg IV SOS
7) INJ OPTINEURON 1amp in 100 ml NS IV OD
8) TAB MVT PO OD
9) TEMP MONITORING 2nd hely
10) BP, PR monitoring 4th hrly
11) GRBS monitoring 6th hrly
 
5/9/0022


 IVF 1 NS, 1 RL , 1DNS@ 75 ml/ hr
2) INJ CEFTRIAXONE 1gm IV BD
3)INJ NEOMOL 1gm IV / SOS( if temp >101°F)
4) INJ ZOFER 4mg sos
5) TAB PCM 650 mg PO TID
6) TAB PAN 40 mg IV SOS
7) INJ OPTINEURON 1amp in 100 ml NS IV OD
8) TAB MVT PO OD
9) TEMP MONITORING 2nd hely
10) BP, PR monitoring 4th hrly
11) GRBS monitoring 6th hrly

6/092022

1)IVF 1 NS, 1 RL , 1DNS@ 75 ml/ hr
2) INJ CEFTRIAXONE 1gm IV BD
3)INJ NEOMOL 1gm IV / SOS( if temp >101°F)
4) INJ ZOFER 4mg sos
5) TAB PCM 650 mg PO TID
6) TAB PAN 40 mg IV SOS
7) INJ OPTINEURON 1amp in 100 ml NS IV OD
8) TAB MVT PO OD
9) TAB HIFENAC PO/ BD
10) TAB NEUROKIND LC HS
11)TEMP MONITORING 2nd hrly
12) BP, PR monitoring 4th hrly
13) GRBS monitoring 6th hrly






 Investigations:












































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