A 51-year-old male presented with high grade fever and generalizedweakness
Dr. Saroar Jahan Rajib
MD Resident (Phase-B)
Haematology
BSMMU
Particulars of the patient
Chief complaints
H/O present illness:
According to the statement of the patient, he was reasonably well 3 months back, then he developed high grade intermittent fever with evening rise of temperature, maximum recorded temperature was 103*F, fever subsided with taking antipyretic and associated with night sweat. Fever is not associated with any chills and rigor.
He also noticed that he is gradually becoming weak and pale. Initially he could perform all activities with little discomfort but now he becomes tired while he does usual daily activities. Along with weakness he occasionally experience vertigo and palpitation specially during strenuous activities.Patient also complaints of gradual weight loss of about 6 kg in last 3 month.Patient devlops maculo-papular rash with clear mirgin and intense itching.His appetite is good and dietary habit is normal. His bladder and bowel habit is regular.
Negative History: No history of
Continued. . .
History of past illness
No previous history of major systemic disease, radiation therapy or other significant chronic illness.
Family history
He is married and have one son and one daughter.
One of his uncle died of hepatocellular Ca.
Personal History: He is non smoker, non alcoholic. He worked as a teacher for last 20 years.
Drug history:No significant drug history.
Treatment History: No significant past treatment history other then received 5 unit of Red blood cell transfusion in this period of illness in last 3 month.
Socioeconomic condition: He belongs to middle socioeconomic condition.
Physical examination
Contd:
Systemic examination:
Cardio-Vascular system
Respiratory system NAD
Nervous system
Musculoskeletal system
Salient features
Mr. Rojot ,51yrs old ,male ,normotensive nondiabetic hindu school teacher hailing from gopalganj admitted in BSMMU with the complaints of High grade intermittent fever for last three months. Gradual progressive fatigue occasionally associated with vertigo and palpitation. Which is hampering his day to day activity.He also complaints of around 6 kg of weight loss in last 3 months.Patient devlops rash with intese itching during hospital stay.
Patient gives no history sore throat,cough with sputum production , joint pain , oral ulcer, any bleeding manifestation, nodular swelling, jaundice, dysuria. He had no significant past history, his family history and drug history was unremarkable. On examination patient is severely anemic , non icteric , maculopapular rash involving mainly chest ,back and limbs with intense itching. Temperature 102*F and mild tachycardia. All other vital parameters are within normal limit.On systemic examination there is hepatomegaly other systemic examination reveals no abnormality.