General medicine case 1

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

A 48 year old male patient presented to the OPD with the chief complaint of fever and swelling in the right lower limb since 4 days.

History of present illness :

- Patient was apparently asymptomatic 4 days back then he noticed a swelling on the right lower leg due to trauma.

 - The swelling is associated with pain, no discharge, no sinuses. 

- It is associated with low grade fever and is intermittent. 

- Fever is not associated with chills and rigors.

History of past illness : 

- There is no history of diabetes, hypertension, asthma, tuberculosis, epilepsy

- There is no history of surgery

- The patient is a known case of filariasis of right leg 20 years ago.

Personal history : 

- Patient has no loss of appetite 

- He takes mixed diet

- His bowel and bladder movements are normal

- He has no habits of cigarette smoking / alcohol

- Low socio - economic status

Family history : 

- No history of DM, hypertension, CAD, CVA or similar complaints in the family.

Treatment history : 

-No treatment taken for present illness

- No history of drug allergy

General examination : 

- Patient is conscious, coherent, and cooperative

- No pallor

- No icterus present

- No clubbing 

- No cyanosis

- No generalised lymphadenopathy

- Pedal edema of right lower leg, non pitting type



Vitals : Temperature : 98.4 F

              Pulse rate : 84 bpm

              Respiratory rate : 24 cycles per minute

              BP : 130/70 mm Hg

               SpO2 : 98 %



Systemic examination : 

Cardiovascular system

Inspection : 

Chest wall is bilaterally symmetrical

No precordial bulge

No visible pulsations, engorged veins, scars, sinuses

Palpation :

JVP is normal

Ausculatation : 

S1 and S2 heard

Respiratory system : 

Position of trachea - central

Bilateral air entry is normal

Normal vesicular breath sounds heard

No added sound

PER abdomen : 

Abdomen is not tender

Bowel sounds heard

No palpable mass or free fluid

Central nervous system : 

Patient is conscious

Speech is present

Reflexes are normal

Provisional diagnosis : 

Viral infection 


Investigations :

08-08-2021

Hemogram - 


Liver function tests - 









NS1 antigen test - 







M. P Strip test




Serum creatinine - 




Blood urea - 




Serum electrolytes - 





Random blood sugar - 



ECG - 


Final diagnosis : 

Dengue with NS1 antigen positive

Treatment : 

- Tab Augmentin 625 mg PO/BD for 5 days

- Tab DEC 100 mg TID for 14 days

- Tab Pantop 40 mg PO/OD/BBF

- Tab MVT PO/OD

- Tab Vit C PO/OD

- Tab Dolo 650 mg PO/SOS






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