A 40 YR old male ,farmer by occupation
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CASE :
A 40 year old male ,resident of Nalgonda ,came to the OPD with
C/O fever since 15 days
C/O head ache since 15 days
C/O pain abdomen since 10 days
C/O blood in stools since morning
Daily routine :
40 yr old male,married for 25 years with 2 kids one daughter and one son lives along with his father and brother. Lives in pacca house with 4 rooms surrounded by compound wall no crack in the walls ( with no pets , has rats and mosquitoes,no cockraches or insects with no stagnant water bodies nearby or drainage )
Shares good relations with all his family members (according to him and his wife ) calm going and not aggressive by nature .
He wakes up at 5 am in the morning and finishes his daily needs and goes to work in the farm by 7 in the morning.His work involves producing millets,feeding cows (has about 4 cows which are near his farm ),exposure to pesticides.On questioning he even mentions about small insects in farms (?ticks).Has his lunch in the farm itself (carries lunch box - mostly rice ) returns home in the evening ,drinks toddy ,eats his dinner and sleeps by 9 - 10 pm .sometimes he even sleeps in the farm.The day before developing of fever he worked more than usual and had history od spraying pesticides.
Gives no history of any insect bite or any travel history
History of present illness :
Pt was apparently asymptomatic 1 year back.later he passed blood in stools for 2 days which was insidious in onset along with painful defecation for which he visited hospital and treated conservatively (given syrup ) and his symptoms got subsided
Around 15 days back he developed high grade,continuous type of fever which is insidious in onset ,gradually progressive with diurnal variation,more during nights subsided on taking medication
C/O pain abdomen more in the left iliac fossa ,non radiating and not associated with nausea/vomitings
C/O headache (more in the frontal region) non radiating ,not associated with diminished or blurring of vision or photophobia
C/O loss of appetite since 1 week
C/O blood in stools since morning -fresh blood ,mixed with stools(hard stools)
No complaints of cough,cold,vomitings or nausea or diarrhoea ,burning micturition
Past history :
No similar complaints in the past
Not a k/c/o of diabetes,hypertension,asthma,epilepsy,thyroid,CVA
No history of any surgeries or blood transfusions in the past
Personal history :
Diet - Veg
Appetite - decreased
Sleep - adequate
Bowel and bladder movements - regular
No known allergies
History of toddy consumption daily since he was 10 years old
History of tobbaco consumption - 10 years back for 10 years (stopped randomly when he got fever 10 yrs back and his fever and appetite got bad with smoking )
General examination :
Pt is conscious, coherent,cooperative
No signs of pallor,icterus,cyanosis ,clubbing, lymphadenopathy,edema
Moderately built and nourished
Eschar seen on left shoulder
Vitals :
PR: 92bpm
BP: 90/60 mmHg
RR: 24
Temp : 102 F
Grbs : 115
Systemic examination :
CVS: S1, S2 heard
RS: BAE present,NVBS heard
Spo2: 97%on room air
P/A: soft ,tenderness present in left iliac fossa region
CNS : No focal neurological deficits
Investigations :
Chest xray :
ECG :
2d echo :
USG abdomen :
Treatment :
On day of admission :
1)IVF -NS and RL @100ml/hr continuously
2)Inj. NEOMOL 100 ml if temp>101 F
3)Inj.PANTOP 40 mg /IV/OD
4)Inj.ZOFER 4 mg /IV/SOS
5)Tab.DOLO 650 mg /PO/TID
6)Tab.DOXYCYCLINE 100 mg /PO/BD
7)Inj.OPTINEURON 1 amp in 100 ml NS /IV/OD
8)Strict I/O Charting
9)Monitor vitals
Surgery referral :
DAY 1 :
S - 3 episodes of fever spikes +,Headache +(diffuse type) ,pain abdomen in left iliac fossa
Passed blood in stools (fresh blood)
O - no signs of pallor,icterus,clubbing,cyanosis ,lymphadenopathy,edema
Temp : 99 F
BP : 130/90 mm Hg
PR : 89 bpm regular in volume
RR: 20 cpm
Spo2 : 97%@RA
I/O : 1900/ 1100 ml
Grbs: 140 mg/dl
CVS:S1,S2heard,no murmur
RS :BAE +,NVBS heard
P/A - soft,tenderness present in left iliac fossa region
A - Viral Pyrexia under evaluation
P -
1)IVF -NS and RL @100ml/hr continuously
2)Inj. NEOMOL 100 ml if temp>101 F
3)Inj.PANTOP 40 mg /IV/OD
4)Inj.ZOFER 4 mg /IV/SOS
5)Tab.DOLO 650 mg /PO/TID
6)Tab.DOXYCYCLINE 100 mg /PO/BD
7)Inj.OPTINEURON 1 amp in 100 ml NS /IV/OD
8)Strict I/O Charting
9)Monitor vitals
DAY 2 :
S - 2 fever spikes +,Headache +(diffuse type)
Passed stools
O - no signs of pallor,icterus,clubbing,cyanosis,
lymphadenopathy,edema
Temp : 99 F
BP : 120/60 mm Hg
PR : 72 bpm regular in volume
RR: 24 cpm
Spo2 : 97%@RA
I/O : 1900/ 1000 ml
CVS:S1,S2heard,no murmur
RS :BAE +,NVBS heard
P/A - soft,tenderness present in umbilical region. and left iliac fossa region
Hemogram
Hb - 12.1
TC - 6400
N/L- 50/43
PCV - 34.0
MCV - 85.4
MCH - 30.4
MCHC - 35.6
RBC - 3.98
PLT - 1.10
A - Viral Pyrexia under evaluation
P -
1)IVF -NS and RL @100ml/hr continuously
2)Inj. NEOMOL 100 ml if temp>101 F
3)Inj.PANTOP 40 mg /IV/OD
4)Inj.ZOFER 4 mg /IV/SOS
5)Tab.DOLO 650 mg /PO/TID
6)Tab.DOXYCYCLINE 100 mg /PO/BD
7)Inj.OPTINEURON 1 amp in 100 ml NS /IV/OD
8)Strict I/O Charting
9)Monitor vitals
Fundoscopy
Day 3 :
S - 1 fever spikes +,Headache +(diffuse type)
Passed stools (non blood tinged )
O - no signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,edema
No eschar
Temp : 98.4 F
BP : 110/70 mm Hg
PR : 76 bpm regular in volume
RR: 22 cpm
Spo2 : 97%@RA
I/O : 2900/ 1700 ml
CVS:S1,S2heard,no murmur
RS :BAE +,NVBS heard
P/A - soft,tenderness present in umbilical region. and left iliac fossa region
Hemogram
Hb - 12.1
TC - 6300
N/L- 47/42
PCV - 33.9
PLT - 1.60
A - scrub typhus positive
P -
1)IVF -NS and RL @100ml/hr continuously
2)Inj. NEOMOL 100 ml if temp>101 F
3)Inj.PANTOP 40 mg /IV/OD
4)Inj.ZOFER 4 mg /IV/SOS
5)Tab.DOLO 650 mg /PO/TID
6)Tab.DOXYCYCLINE 100 mg /PO/BD
7)Inj.OPTINEURON 1 amp in 100 ml NS /IV/OD
8)SYP.LACTULOSE 10 ml PO/HS
9)Inj.CEFTRIAXONE 1gm/IV/BD
9)Strict I/O Charting
10)Monitor vitals
Day 4 :
S - 1 fever spike +,no c/o headache
Pain abdomen decreased
Passed stools (non blood tinged )
O - no signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,edema
No eschar
Temp : 98.9 F
BP : 110/70 mm Hg
PR : 70 bpm regular in volume
RR: 20 cpm
Spo2 : 98%@RA
I/O : 3200/ 2250 ml
CVS:S1,S2heard,no murmur
RS :BAE +,NVBS heard
P/A - soft,tenderness present in umbilical region and left iliac fossa region
Hemogram
Hb - 12.6
TC - 6200
N/L- 35/60
PCV - 36.6
PLT - 2.17
RBC -4.29
MCV -85.3
MCH -29.5
MCHC - 34.6
A - Rickettsial fever (scrub typhus positive )
P -
1)IVF -NS and RL @100ml/hr continuously
2)Inj. NEOMOL 100 ml if temp>101 F
3)Inj.PANTOP 40 mg /IV/OD
4)Inj.ZOFER 4 mg /IV/SOS
5)Tab.DOLO 650 mg /PO/TID
6)Tab.DOXYCYCLINE 100 mg /PO/BD
7)Inj.OPTINEURON 1 amp in 100 ml NS /IV/OD
8)SYP.LACTULOSE 10 ml PO/HS
9)Inj.CEFTRIAXONE 1gm/IV/BD
9)Strict I/O Charting
10)Monitor vitals
Day 5
S - 1 fever spike +,no c/o headache
Pain abdomen decreased
Passed stools (non blood tinged )
O - no signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,edema
No eschar
Temp : 98.9 F
BP : 110/70 mm Hg
PR : 70 bpm regular in volume
RR: 20 cpm
Spo2 : 98%@RA
I/O : 3200/ 2250 ml
CVS:S1,S2heard,no murmur
RS :BAE +,NVBS heard
P/A - soft,tenderness present in umbilical region and left iliac fossa region
Hemogram
Hb - 12.2
TC - 5500
N/L- 30/60
PCV - 36.1
PLT - 1.51
RBC -4.18
MCV -86.4
MCH -29.2
MCHC - 33.8
A - Rickettsial fever (scrub typhus positive )
P -
1)IVF -NS and RL @100ml/hr continuously with 1 amp optineuron
2)Inj. NEOMOL 100 ml if temp>101 F
3)Inj.PANTOP 40 mg /IV/OD
4)Inj.ZOFER 4 mg /IV/SOS
5)Tab.DOLO 650 mg /PO/SOS
6)Tab.DOXYCYCLINE 100 mg /PO/BD
7)SYP.LACTULOSE 10 ml PO/HS
8)Inj.CEFTRIAXONE 1gm/IV/BD
9)Strict I/O Charting
10)Monitor vitals
http://keelasreevalli.blogspot.com/2021/10/a-40-yr-old-male-farmer-by-occupation.html
Discharge summary :
A 40 year old male ,resident of Nalgonda ,came to the OPD with
C/O fever since 15 days
C/O head ache since 15 days
C/O pain abdomen since 10 days
C/O blood in stools since morning
Daily routine :
40 yr old male,married for 25 years with 2 kids one daughter and one son lives along with his father and brother. Lives in pacca house with 4 rooms surrounded by compound wall no crack in the walls ( with no pets , has rats and mosquitoes,no cockraches or insects with no stagnant water bodies nearby or drainage )
Shares good relations with all his family members (according to him and his wife ) calm going and not aggressive by nature .
He wakes up at 5 am in the morning and finishes his daily needs and goes to work in the farm by 7 in the morning.His work involves producing millets,feeding cows (has about 4 cows which are near his farm ),exposure to pesticides.On questioning he even mentions about small insects in farms (?ticks).Has his lunch in the farm itself (carries lunch box - mostly rice ) returns home in the evening ,drinks toddy ,eats his dinner and sleeps by 9 - 10 pm.The day before developing of fever,he worked more than usual and has history of sleeping in the farm 2 days ago and spraying of pesticides
Gives no history of any insect bite or any travel history
History of present illness :
Pt was apparently asymptomatic 1 year back.later he passed blood in stools for 2 days which was insidious in onset along with painful defecation for which he visited hospital and treated conservatively (given syrup ) and his symptoms got subsided
Around 15 days back he developed high grade,continuous type of fever which is insidious in onset ,gradually progressive with diurnal variation,more during nights subsided on taking medication
C/O pain abdomen more in the left iliac fossa ,non radiating and not associated with nausea/vomitings
C/O headache (more in the frontal region) non radiating ,not associated with diminished or blurring of vision or photophobia
C/O loss of appetite since 1 week
C/O blood in stools since morning -fresh blood ,mixed with stools(hard stools)
No complaints of cough,cold,vomitings or nausea or diarrhoea
Past history :
No similar complaints in the past
Not a k/c/o of diabetes,hypertension,asthma,epilepsy,thyroid,CVA
No history of any surgeries or blood transfusions in the past
Personal history :
Diet - Veg
Appetite - decreased
Sleep - adequate
Bowel and bladder movements - regular
No known allergies
History of toddy consumption daily since he was 10 years old
History of tobbaco consumption - 10 years back for 10 years (stopped randomly when he got fever 10 yrs back and his fever and appetite got bad with smoking )
General examination :
Pt is conscious, coherent,cooperative
No signs of pallor,icterus,cyanosis ,clubbing, lymphadenopathy,edema
Moderately built and nourished
Vitals :
PR: 92bpm
BP: 90/60 mmHg
RR: 24
Temp : 102 F
Grbs : 115
Systemic examination :
CVS: S1, S2 heard
RS: BAE present,NVBS heard
Spo2: 97%on room air
P/A: soft ,tenderness present in left iliac fossa region
CNS : No focal neurological deficits
Treatment :
On day of admission :
1)IVF -NS and RL @100ml/hr continuously
2)Inj. NEOMOL 100 ml if temp>101 F
3)Inj.PANTOP 40 mg /IV/OD
4)Inj.ZOFER 4 mg /IV/SOS
5)Tab.DOLO 650 mg /PO/TID
6)Tab.DOXYCYCLINE 100 mg /PO/BD
7)Inj.OPTINEURON 1 amp in 100 ml NS /IV/OD
8)Strict I/O Charting
9)Monitor vitals
Advice at discharge :
1)Plenty of oral fluids
2)TAB.DOXYCYCLINE PO/BD
3)TAB.PAN 40 MG PO/OD
4)TAB.ZOFER 4 MG PO/SOS
5)SYP.MUCAINE GEL PO/HS
6)TAB.DOLO 650 MG PO/SOS
Follow up :
Review to opd after 2 weeks (on Monday)
