19 Year old male with fever and lower backache

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

This is a case of 19 year old male hailing from mirylaguda who is intermediate second year student came to general medicine OPD with chief complaints of 

CHIEF COMPLAINTS 

Fever since 3 days 

Lower back ache since 3 days

Generalized weakness since 3 days

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 10 days back then he developed high grade fever which was continuous ,no diurnal variation which got relieved on medication given by local RMP [some IV medication was given for 1 day and oral medication for 3 days].

Now again since 3 days he had high grade fever which was continuous not associated with chills and rigor ,no diurnal variation

He had one episode of vomiting today i.e 30 Nov 2022 which was non projectile contained food particles

He also complained of low back ache since 3 days which is insidious in onset ,gradually progressive, and is persistent and pain increased during inspiration and no relieving factors.[he was unable to describe the character of pain]

He also complained of abdominal pain which is insidious in onset persistent not associated with nausea and vomiting

He also complained of generalized weakness since 3 days 

No history of burning micturition, increased frequency of urine ,difficulty to pass urine ,nocturnal eneursis

No history of loose stools 

PROVISIONAL DIAGNOSIS 

 Dengue fever (NS 1 positive)

?pyelonephritis ( USG)

? serositis 

TREATMENT

1.IVF- NS/RL @75ml/hr

2.INJ PANTOP 40mg/IV/OD

3.TAB DOLO 650mg/PO/TID

4.TAB ZOFER 4mg/PO/SOS

5.INJ NEOMOL 100ml