A 25-year-old male presented with a 4-day history of mild intermittent fever. His symptoms and examination were not suggestive of common causes of fever like URTI, LRTI, gastroenteritis, or UTI. His blood tests showed normal white blood cell count with lymphocytosis. He was diagnosed with a viral fever and prescribed paracetamol. After 4 days he returned with high fever, cough, and left-sided chest pain and breathing difficulty. Examination found reduced breathing sounds and dullness on the left chest. A chest X-ray showed left lung consolidation consistent with pneumonia. He was treated as an outpatient with oral antibiotics.

1.  SYMPTOM EVALUATION

2.  25 yrs. old Yasith is presented to OPD with 4
days history of fever.He is having gradual
onset mild intermittent fever.It is responded
to paracetamol,not associated with chills and
rigors.no diurnal variation of fever.

3. Very common causes
 Viral fever
 URTI
 LRTI
 Dengue
 Gastroenteritis
 UTI
 Ear infection

4.  Malaria
 Viral hepatitis
 Tuberculosis
 Meningitis
 Soft tissue infection ex:cellulitis
 Typhoid
 Leptospirosis
 Infectious mononucleosus
 Communicable diseases;chicken
pox,mumps,rubella

5.  Infective endocarditis
 Scrub typhus
 Neoplasm;lymphoma,leukaemia,renal cell CA

6.  URTI,LRTI,TB????No respiratory
symptoms;cough,no evening pyrexia,night
sweats,weight loss
 GASTROENTERITIS???No GI
symptoms;vomiting,diarrhoea,intake of
contaminated food
 UTI,PYELONEPHRITIS???No urinary
symptoms;dysuria,frequency
 SINUSITIS,LEPTOSPIROSIS,MENINGITIS??No
headache,severe body pains,dark
urine,conjunctival suffusion,not drowsy
 MALIGNANCY???No recurrent episodes of fever

7.  No significant sexual Hx,drug Hx
 Social Hx;
 Occupation-computer engineer-no risk of
occupational infections
 No recent travel to malarial endemic
area,forest,abroad
 No contact Hx of TB,hepatitis,communicable
disease

8.  Temparature-mild fever,no facial flushing
 ,no icterus,no pallor,no rashes
 ,no lymphadenopathy
 ,BCG scar-present,ENT-NL,no sinus
tenderness
 No neck stiffness,kernic sign-negative
 System examination-NL-no RS signs,no
hepatosplenomegaly
 CVS-no murmurs

9.  As patient is having 4 days Hx of fever,we can
do FBC as basic Ix
 Hb 13.5 g/dl
 RBC 5 X 1012/l
 WBC-9 x 109/l
 Neutrophils 2 x 109/l
 Lymphocytes 5 x 109/l
 PLT 250 X 109/l

10.  Viral fever

11.  Paracetamol 10-15mg/kg of body weight per
dose 6hry(maximum dose 60mg/kg/day)
 If high fever,-tepid sponging
 If temperature is not
settling,ibuprofen(20mg/kg/day) or mefanamic
acid(25mg/kg/d) can be given.but C/I in dengue
 Increase in fluid intake to prevent dehydration
 Educate carer about danger signs
 Review in 3 days(,earlier than that ,if condition is
nt improved)

12.  When to refer
 Fever>10days
 Ill look/tachycardia/respiratory distress
 Poor response to Rx
 Persistent vomiting/not taking orally
 When Iv antibiotics are indicated-
pyelonephritis,meningitis

13. After 4 days the patient again
presented with high grade
intermittent fever and cough with
purulent sputum. He had
developed shortness of breathing
with mild chest pain which is
intensified by inspiration and
coughing

14.  Patient is febrile, not pale,
 Pulse rate -86/min
 Respiratory rate -28/min
 Blood pressure-110/80mmHg
 Chest expansion has reduced in left side
 percussion note is dull in left middle area of
the chest
 On auscultation-coarse crepitation mainly at
left middle area

15. Probable diagnosis is
lower respiratory tract
infection, most probably
pneumonia

16.  Full blood count-neutrophil count was
increased
 chest X-ray- consolidation in the left middle
lobe

17.  It is done by CURB 65 score
 C-confusion
U-urea>7mmol
R-respiratory rate>30/min
B-blood pressure-systolic<90 or
diastolic<60
age-more than 65


18.  If the score
score 0-1- can treat as out patient
score 2 -admit the patient
score 3+ -require ICU care

19.  Since this patient CURB score is < 2 we can treat
him as out patient
Treatment
 can treat by oral antibiotics
Amoxycilline 500mg 8hrly
or
Erythromycin 500mg tds and
clarythromicin 500mg bd