Viral Pyrexia

 This is an online E-Log book to discuss our patient's de-identified 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 these patient's clinical problems with collective current best evidence-based inputs. This E-log also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome.


CASE : 


A 62 year old male came to casuality on 9/01/2022 at 2 am with chief complaints of fever with chills 


CHIEF COMPLAINTS:


Fever since 3days associated with chills relieved on medication


HOPI:


Patient was apparently asymptomatic 3 days ago then he developed High grade fever associated with chills, relieved on medication.


No h/o cough and cold 


No h/o vomiting, loose stools.


PAST HISTORY:


No similar complaints in past.


He is a k/c/o of Diabetes since 15 years and is on medication for the same. ( Metformin)


Not a k/c/o HTN, CVA, CAD, TB, EPILEPSY, ASTHMA.


PERSONAL HISTORY:  

Diet- Mixed

Appetite- Normal

Bowel and bladder movements- Regular

Sleep- Adequate

Addictions- H/o alcohol consumption 90ml/day since 40 years , smoking beedi one packet/day for 40years.

Surgical history-No h/o previous surgeries.


FAMILY HISTORY:

Not significant.


GENERAL EXAMINATION : 

The patient was examined in a well-lit room after informed consent was taken. He is conscious, coherent, cooperative, well oriented to time, place and person.He is well nourished and moderately built.


  1. No Pallor
  2. No Icterus
  3. No Clubbing 
  4. No Cyanosis
  5. No Koilonychia
  6. No Lymphadenopathy
  7. No Edema.

VITALS : 

  1. Temperature- 99.4°F
  2. Pulse Rate- 90 bpm
  3. RR- 22cpm
  4. BP- 100/70 mmHg
  5. SpO2- 98% at room air
  6. GRBS: 402mg/dl




SYSTEMIC EXAMINATION:

  1. CVS: s1 s2 heard
  2. P/A: soft,non tender,no guarding or rigidity.
  3. Respiratory system:  BAE+; NVBS
  4. CNS: No focal deficits







INVESTIGATIONS : 


LIVER FUNCTION TESTS 













SERUM ELECTROLYTES : 









ABG : 






SERUM CREATININE : 






CHEST X RAY : 









PROVISIONAL DIAGNOSIS  : 

?VIRAL PYREXIA under evaluation 

? Alcoholic liver disease 


TREATMENT : 

  1. IVF- NS ,RL @100ml/hr
  2. Inj. PAN 40mg IV OD
  3. Inj. OPTINEURON 1amp in 100ml NS IV OD
  4. TAB. DOLO 650mg PO SOS
  5. Inj. NEOMOL 1G IV SOS (only if temperature>101°F)
  6. Inj. HAI according to GRBS
  7. BP, PR monitoring 4th hourly
  8. Inform SOS
  9. GRBS monitored at 8am,2pm,8pm.                         





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