29 year old with fever and loose stools

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I’ve 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.

Following is the view of my case :

Date of admission :29/10/22

A 29 year old male patient came to the opd with chief complaints of fever since 2 days,loose stools since 2 days

History of present illness :

Patient was apparently asymptomatic 2 days back then he developed :

H/o Fever-

Onset - 

Duration- since 2 days

Type - intermittant ,high grade  

It was relieving on taking medications .

Associated with chills and rigors.

Diurnal variation absent

No rise of temperature at night

H/o loose stools:

Onset - sudden

Duration- 2 days

No.of episodes -3 episodes per day

Consistency- watery

Volume -normal

Colour - yellow colour

Non foul smelling

No c/o headache,body pains,cold,cough,sob, bleeding manifestations, burning micturition.

Daily routine: Patient is a worker at a petrol station often does 24 hours shift and gets a day off

Eats breakfast at :9-10 am

Lunch at:2:30pm

Dinner at :9:00 pm

Past history:

Not a known case of, 

Hypertension, diabetes, epilepsy, CAD, asthma, thyroid.

Personal history :

Diet - mixed

Appetite - normal

sleep - adequate

Bowel and Bladder movements -passing watery stools

Addictions - no

No known allergies

Drug history : 

No significant drug history

Family history :

No significant family history

General examination :

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

at the time of examination

He is examined in a well lit room, with consent taken.

He is moderately built and well nourished.

Pallor - absent

Icterus - absent

Cyanosis - absent 

Clubbing - absent

lymphadenopathy - absent

Pedal edema - absent 

Vitals : on the day of admission:(29/10/2022)

Temperature - 99°F

Pulse rate - 82 bpm

Respiratory rate - 16 cpm

Blood pressure - 110/80 mm Hg

SpO2 - 99% on Room air

GRBS - 97mg/dl

Systemic examination:

CVS : 

S1 and S2 heart sounds heard

NO murmurs and thrill

RESPIRATORY SYSTEM : 

Bilateral air entry present

 position of trachea - central

Vesicular breathsounds heard

CNS : intact

ABDOMEN: 

Soft,nontender 

On deep palpation: no palpable mass

No organomegaly

Bowel sounds heard 

Investigations:

Diagnosis:

Dengue with Bicytopenia(WBC,PLATLETS)

Treatment:

1)IV fluids : 2*NS 1*RL

2)plenty oral fluids

3)strict temperature charting 4 th hourly

4)T.Dolo 650 mg /PO/SOS

5)Inj.Neomol 1gm IV SOS(if temp >101°F)

6)Tab.Pan 40 mg PO/OD

7)W/F bleeding manifestations,postural hypotension