A 40 YR old male ,farmer by occupation


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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 a diagnosis and treatment plan.

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)





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