A 56 YEAR OLD MALE
A 56 YEAR OLD MALE CAME WITH THE C/O FEVER SINCE 20 DAYS
GENERALIZED BODY PAINS SINCE 10 DAYS
LOSS OF APPETITE SINCE 15 DAYS
NO H/O LOOSE STOOLS,COLD,COUGH,PAIN ABDOMEN,MALENA
HISTORY OF PRESENT ILLNESS:
FEVER SINCE 20 DAYS WHICH WAS LOW GRADE, INTERMITTENT, SUDDEN IN ONSET,NOT ASSOCIATED WITH CHILLS AND RIGORS, RASH.
BODY PAINS GRADUALLY PROGRESSIVE IN NATURE AND INCREASED WITHOUT TAKING FOOD.
HEADACHE SUDDEN IN ONSET, DRAGGING TYPE, PRESENT IN B/L FRONTAL REGIONS, SOMETIMES DIFFUSES TO PARIETAL REGION, INCREASED WITH FEVER SPIKES (AT NIGHT TIMES)
PAST HISTORY:
K/C/O HTN SINCE 5 MONTHS
2 MONTHS BACK HE HAD SURGERY FOR HYDROCELE
PERSONAL HISTORY
DIET- MIXED
APPETITE-DECREASED
SLEEP-REDUCED
REGULAR BOWEL AND BLADDER MOVEMENTS
ADDICTIONS-DRINKS ALCOHOL SINCE 10 YRS (3 TIMES/MONTH ) STOPPED 2 YRS BACK
SMOKES CIGARETTE SINCE 10 YRS ( DAILY 2 TO 3 PER DAY) STOPPED 2 YRS BACK
VITALS
PR-98 BPM
BP-100/80 MM HG
GRBS-101MG/DL
RR-16 CPM
GENERAL EXAMINATION
NO PALLOR, ICTERUS, CLUBBING, CYANOSIS, PEDAL EDEMA, LYMPHADENOPATHY
SYSTEMIC EXAMINATION
CVS-S1,S2 HEARD
RS-BAE +
PER ABDOMEN- SOFT,NON TENDER
CNS- NFND
PROVISIONAL DIAGNOSIS
UNDIFFERENTIATED FEVER
K/C/O HTN SINCE 5 MONTHS
INVESTIGATIONS
ON 4/9/21
On 6/9/21
FEVER CHART
TREATMENT :
ON 4/9/21
1.INJ .OPTINEURON 1 AMP IN 100 ML NS IV ) OD
2.INJ.NEOMAL 100 ML IV/SOS
3.INJ.PANTOP 40 MG IV/OD
4.INJ.ZOFER 4MG IV/SOS
5.TAB.PCM 650 MG PO/TID
6.TAB.ULTRACET PO/QID
7.BP/PR/TEMP/RR 4TH HRLY
8.TAB.TELMA 40 MG PO/OD
ON 5/9/21
1.INJ .OPTINEURON 1 AMP IN 100 ML NS IV ) OD
2.INJ.NEOMAL 100 ML IV/SOS
3.INJ.PANTOP 40 MG IV/OD
4.INJ.ZOFER 4MG IV/SOS
5.TAB.PCM 650 MG PO/TID
6.TAB.ULTRACET PO/QID
7.BP/PR/TEMP/RR 4TH HRLY
8.TAB.TELMA 40 MG PO/OD1.INJ
ON 6/9/21
1 INJ.OPTINEURON 1 AMP IN 100 ML NS IV ) OD
2.INJ.NEOMAL 100 ML IV/SOS
3.INJ.PANTOP 40 MG IV/OD
4.INJ.ZOFER 4MG IV/SOS
5.TAB.PCM 650 MG PO/TID
6.TAB.ULTRACET PO/QID
7.BP/PR/TEMP/RR 4TH HRLY
8.TAB.TELMA 40 MG PO/OD
