August 11,2021
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A 48 yr old male patient presented to OPD with chief complaints of fever, swelling in the right lower limb since 4 days
History of present Illness
Patient was Apparently Asymptomatic 1 week back then developed Fever and Swelling in the Right Lower Limb
Fever:Low grade, intermittent and fever associated with chills
Swelling:Patient had trauma on right lower limb 4 days back,by which patient noticed swelling over right lower limb.
Onset: Insidious
Duration:4 days
Progression:Gradual
Pain over swelling ,No discharge
Past History:
No history of DM and HTN
The patient had Right Lower limb filariasis 20 yrs ago.
Due to filariasis the patient used to have episodes of fever for every 6 months since 20 yrs ,he used to take medication and fever relieved.
Recently swelling appeared after 3 yrs with fever spike since 1 week, along with that,his trauma which occurred 4 days back increased his swelling on right lower limb.
Family History:
No similar complaints in the family history
Personal History:
Diet:Mixed
Appetite: Normal
Sleep: Adequate
Bowel and Bladder movements: Normal
Addictions: Absent
General Examination
No Pallor
No Icterus
No Cyanosis
No koilonychia
No Lymphadenopathy
No Edema
Vitals
Temperature:98F
Bp:120/70mmHg
Pulse rate:78 bpm
Respiratory Rate:23 bpm
Systemic Examination
PER Abdomen:
No Abdominal Tendorness
No engorged veins
CVS
S1 S2 heard
No murmurs
CNS
Patient is conscious
Reflexes are normal
Provisional Diagnosis:
Dengue, NS1 antigen Positive
Fever Chart
Dengue Rapid Test
Malarial parasite Test
Liver function Test
Complete Urine Examination
Random Blood Sugar
Blood Urea
Serum Electrolytes
ECG
Final Diagnosis
Dengue with NS1 Antigen Positive
Treatment
Iv fluids@75ml/hr
Tab PCM 650 mg
Tab Augmentin 625mg
Tab PAN 40mg
Tab MVT
Tab VitC
Temperature should be checked before giving PCM
Temperature charting should be done 4 th hourly.
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