A 16 year Old male Complains of fever and legs pain

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

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 histoty, clinical findings, .investigations and come up with a diagnosis and treatment plan.

Sir this case was taken on October 30 , 2022

DATE OF ADMISSION OF PATIENT :22-10-2022.

C/O:

 Severe fever and legs pain since 4 days.

HOPI: 

16 year old boy, fast food centre master by occupation, came to the casualty with complaints of severe fever and legs pain since 4 days.

Patient was apparently asymptomatic and had a good appetite before.

He slowly developed fever,legs pain since 4 days, abdominal pain since 1 day, vomitings 6-7 episodes/day, bilious loose stools 4-5 episodes/day( liquid consistently).

Patient was diagnosed and told that he had high creatinine levels due to which he had to undergo dialysis.

He was asked to get admitted in the hospital to undergo dialysis.

Patient is admitted in the hospital on 

22-10-2022.

He has undergone his 1st session of dialysis on 29-10-2022.

Hence, he has undergone 1 session of dialysis.

Before undergoing dialysis on 25-10-2022 his creatinine levels were 5.9mg/dl.

 

PAST HISTORY:

No similar complaints in the past. 

PERSONAL HISTORY:

Appetite- Normal

Sleep- adequate

Bowel and Bladder movements- Regular.

Addictions- alcohol(regular since 6 years)

                    Smoking(regular since 6 years)

                    Drugs(cannabis regular since 6 years).

Diet- Mixed.(junk food).

Allergies-No allergies.

FAMILY HISTORY: Insignificant.

VITALS:

Temp- 99.1 F

PR- 104 bpm

BP- 80/60 mmHg 

RR- 18 cpm

SPO2- 98% at RA.

GENERAL EXAMINATION:

Pallor: No

Icterus: No

Cyanosis: No

Clubbing: No

Lymphadenopathy:No

Edema: No

INVESTIGATIONS ;

ESR

CUE

HEMOGRAM

LFT

BLOOD UREA 

ECG

DIAGNOSIS: Impaired kidney function.

TREATMENT:

Inj LASIX 40mg IV/BD

Inj PAN 40mg IV/OD

Ing IOFER 4mg IV/OD

T NODOSIS 500mg PO/BD

T OROFER XT PO/OD.