26M with fever, vomitings and loose stools

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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 competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan 

A 26 year old male' driver by occupation, presented to GM OPD on  with

Chief complaints-

C/o fever since 12 days

c/o generalised weakness and headache since 12 days 

c/o vomitings since 9 days

c/o loose stools since 9 days

History of presenting illness

Patient was apparently asymptomatic 12 days ago, then, he developed fever which was high grade, intermittent, associated with chills and rigor.

He developed vomitings 9 days ago, 5 episodes, with food as content, non bilious, non projectile, non blood stained

Loose stools 9 days ago, 3 episodes/day, watery, green coloured, not blood stained.

H/o  green coloured stools since 9 days.He apparently drank papaya leaf juice for 3days in the morning prior to the episodes of loose stools.

He also had headache and generalised weakness since 12 days

He visited a doctor but symptoms still persisted so he came to our hospital on 7/6/23

 

Past history

Not a k/c/o DM, HTN, Tuberculosis,epilepsy, asthma.

No H/o similar complaints in the past

Personal history 

Appetite-Normal

Diet-mixed

Bowel movements- increased

Sleep-Adequate

Addictions- Has been drinking alcohol (375ml) everyday since 6 years 

Family history

Insignificant

 Treatment history 

Paracetamol and sporlac

General examination 

Patient is conscious, coherent and cooperative; well oriented to time,place and person

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema 

Vitals

Temp- 99.8°F

PR- 84 bpm

RR- 16 cpm

BP- 100/70mmHg

Systemic examination

GIT

Inspection-

Shape of the abdomen- Scaphoid

Umblicus- inverted 

No scar,pigmentation, engorged veins ,peristaltic waves.

Hernial orifices are normal.

All quadrants move equally with  respiration

Palpation

No local rise in temperature

Liver span- 14cm

Consistency-soft,non tender

Surface-smooth

Margins-rounded

Percussion

Tympanic resonance heard.

Auscultation

Gurgling bowel sounds heard.

RS-B/L air entry present 

      Normal vesicular breath sounds heard

      

CVS- S1S2 present, no murmurs heard

Investigations 

        Liver function tests

  

   Haemogram

Fever chart

Diagnosis:

Pyrexia w/ pancytopenia and hepatomegaly 

?Malaria

Treatment:

1.IV FLUIDS NS, DNS, RL@ 50 ml/hr  

2. Inj. Doxycycline 100mg IV/BD

3. Plenty of oral fluids

4.Protein rich diet

5.Monitor vitals