48 years old male patient with low grade fever

 

General medicine case1


A 48 year old male patient presented to the OPD with the chief complaint of fever and swelling in the right lower limb since 4 days.

History of present illness :

- Patient was apparently asymptomatic 4 days back then he noticed a swelling on the right lower leg due to trauma.

 - The swelling is associated with pain, no discharge, no sinuses. 

- It is associated with low grade fever and is intermittent. 

- Fever is not associated with chills and rigors.

History of past illness : 

- There is no history of diabetes, hypertension, asthma, tuberculosis, epilepsy

- There is no history of surgery

- The patient is a known case of filariasis of right leg 20 years ago.

Personal history : 

- Patient has no loss of appetite 

- He takes mixed diet

- His bowel and bladder movements are normal

- He has no habits of cigarette smoking / alcohol

- Low socio - economic status

Family history : 

- No history of DM, hypertension, CAD, CVA or similar complaints in the family.

Treatment history : 

-No treatment taken for present illness

- No history of drug allergy

General examination : 

- Patient is conscious, coherent, and cooperative

- No pallor

- No icterus present

- No clubbing 

- No cyanosis

- No generalised lymphadenopathy

- Pedal edema of right lower leg, non pitting type



Vitals : Temperature : 98.4 F

              Pulse rate : 84 bpm

              Respiratory rate : 24 cycles per minute

              BP : 130/70 mm Hg

               SpO2 : 98 %

Systemic examination : 

Cardiovascular system

Inspection : 

Chest wall is bilaterally symmetrical

No precordial bulge

No visible pulsations, engorged veins, scars, sinuses

Palpation :

JVP is normal

Ausculatation : 

S1 and S2 heard

Respiratory system : 

Position of trachea - central

Bilateral air entry is normal

Normal vesicular breath sounds heard

No added sound

PER abdomen : 

Abdomen is not tender

Bowel sounds heard

No palpable mass or free fluid

Central nervous system : 

Patient is conscious

Speech is present

Reflexes are normal

Provisional diagnosis : 

Viral infection 


Investigations :

08-08-2021

Hemogram - 


Liver function tests - 









NS1 antigen test - 







M. P Strip test




Serum creatinine - 




Blood urea - 




Serum electrolytes - 





Random blood sugar - 



ECG - 


Final diagnosis : 

Dengue with NS1 antigen positive

Treatment : 

- Tab Augmentin 625 mg PO/BD for 5 days

- Tab DEC 100 mg TID for 14 days

- Tab Pantop 40 mg PO/OD/BBF

- Tab MVT PO/OD

- Tab Vit C PO/OD

- Tab Dolo 650 mg PO/SOS

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