51 YR OLD MALE WITH FEVER SINCE 5 DAYS
4/1/2023
USG Abdomen
CUE
RBS
LFT
G MEGHANA , INTERN
Roll.no :51
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51 YR OLD MALE WITH FEVER AND BODY PAINS SINCE 5 DAYS
A 51 yr old male who is an agricultural labourer came to OPD with
CHIEF COMPLAINTS :
- Fever since 5 days
- body pains since 5 days
- loss of appetite and burning micturition since 5 days
- reduced appetite since 5 days
HISTORY OF PRESENT ILLNESS:
- Patient was apparently asymptomatic 5 days back , he then developed fever , intermittent in nature .Fever is usually low during day time , it later increases during night time , high grade associated with chills and rigors . Patient consulted a local RMP and took injections and used Dolo for fever . Fever relieved on taking antipyretic , again recurs .
- Fever is associated with intermittent episodes of headache , associated with retroorbital pain .
- Reduced appetite and since 5 days .
- patient had intermittent dry cough for 3 days
- he complaints of burning micturition and rescued urine output since 5 days .
- No H/O SOB , cold , nausea , vomitings , palpitations,
Daily routine :
Pt wakes up at 5:30 am , he works as an agricultural labourer since 20 yrs , he has tea breakfast around 7:30 am and goes to work in farm by 8 , at around 1 pm he has lunch ( usually rice ) , comes back home by 6 pm and relaxes , watching TV , completes dinner by 8:30 pm and sleeps by 9 pm
PAST HISTORY :
Not a K/C/O DM, HTN , ASTHMA, EPILEPSY , TB , CAD
H/O hydrocele surgery 20 yrs back
FAMILY HISTORY : Not significant
PERSONAL HISTORY :
Diet - mixed
Appetite - reduced
Bowel movements - regular , bladder movements - reduced
Sleep - adequate
Addictions : occasionally consumes toddy
Allergies : Nil
GENERAL EXAMINATION :
- Patient was examined after taking his consent
- Patient is conscious , coherent , cooperative , well oriented to time , place and person .He is moderately built and nourished
- No signs of pallor , icterus , cyanosis , clubbing , oedema , lymphadenopathy
His vitals:
Temperature : afebrile
BP : 120/80 mm HG
Pulse rate : 78 / min
Resp.rate : 16 cpm
GRBS : 275 mg/dl
Systemic Examination:
CVS- S1 S2 heard,no murmurs present.
RS - bilateral Air entry present
Normal vesicular breath sounds heard
Per Abdomen : soft , non tender
CNS :higher mental functions : normal
Reflexes :
MOTOR-: normal tone and power
reflexes:
RT LT
Biceps ++ ++
Triceps ++ ++
Supinator ++. ++
Knee ++ ++
Ankle ++ ++
Investigations:
ECG
Chest X Ray
RFT
Hemogram
VIRAL PYREXIA WITH THROMBOCYTOPENIA
Management:
- Nebulisation with salbutamol 4 respules IV/ stat
- IV fluids NS , RL @ 100 ml / hr
- Tab . Dolo 650 mg PO / TID
- Inj .Neomol 1 gm IV /SOS if temp > 101 F
- inj .Optinueron 1 amp in 100 ml NS PO/OD
- syp .Citralka 10 ml PO /TID
- plenty of oral fluids
- strict I/O charting
- Vitals monitoring 6 th hrly
- temperature charting 4 th hrly
5/1/2023
S : no fever spikes
Stools not passed
O :
pt is conscious , coherent , cooperative
Temp : 98.5 F
BP :100/70 mm hg.
PR : 98
RR : 16 cpm
Spo2: 98 % at RA
GRBS : 200 mg /dl
I/O : 1900 / 1250
CVS : S1 , S2 heard
RS :BAE + , NVBS
P/A : soft , non tender
CNS : NAD
A :
Viral pyrexia with thrombocytopenia, AKI ( pre renal )
P :
- IV fluids NS , RL @ 100 ml / hr
- Tab . Dolo 650 mg PO / TID
- Inj . Optinueron in 100 ml NS IV/OD
- Inj .Neomol 1 gm IV /SOS if temp > 101
- plenty of oral fluids
- strict I/O charting
- Vitals monitoring 6 th hrly
- temperature charting 4 th hrly
- 2 egg whites per day
6/1/23
SOAP NOTES
AMC
Bed no 4
Day 3
Unit 3
Dr.Nikitha (SR )
Dr.Vamshi Krishna ( PG 3 )
Dr. Nishitha ( PG 2 )
Dr.Govardhini Reddy ( PG 1 )
Dr. Meghana ( intern )
Dr. Tejarshini ( intern)
S : no fever spikes
Stools not passed
SOB +
O :
pt is conscious , coherent , cooperative
Temp : 98.5 F
BP :130/70 mm hg.
PR : 68
RR : 16 cpm
Spo2: 98 % at RA
GRBS : 77 mg /dl
I/O :800 / 600
CVS : S1 , S2 heard
RS :BAE + , NVBS
P/A : soft , non tender
CNS : NAD
A :
Viral pyrexia with thrombocytopenia ( polyserositis - ascites )
? Denovo DM 2
DCMP
P :
- IV fluids NS , RL @ 100 ml / hr
- Tab . Dolo 650 mg PO / TID
- plenty of oral fluids
- strict I/O charting
- Vitals monitoring 6 th hrly
- temperature charting 4 th hrly
- 2 egg whites per day
- Inj .HAI sc acc to GRBS
- GRBS 7 profile
7/1/24
SOAP NOTES
AMC
Bed no 4
Day 4
Unit 3
Stools not passed ,no fever spikes , SOB decreased .
O :
pt is conscious , coherent , cooperative
Temp : 98 F
BP :120/90 mm hg.
PR : 92 bpm
RR : 22 cpm
Spo2: 97 % at RA hu
GRBS : 77 mg /dl
I/O :1600/ 1150 ml
CVS : S1 , S2 heard
RS :BAE + , NVBS +
P/A : soft , non tender
CNS : NAD
A :
Viral pyrexia under evaluation { thrombocytopenia ( resolving )( polyserositis - ascites ) }
Denovo DM 2
DCMP secondary to alcohol intake ? Wet beri beri with prerenal AKI ( resolving )
P :
- IV fluids 1 unit NS @ 75 ml / hr
- Tab . Dolo 650 mg PO / SOS
- plenty of oral fluids
- strict I/O charting
- Vitals monitoring 6 th hrly
- temperature charting 4 th hrly
- 2 egg whites per day
- Inj .HAI sc acc to GRBS
- GRBS 7 profile
- Inj thiamine 200 mg IV / BD in 100 ml NS
8/1/23
S: stools not passed
No fever spikes
SOB decreased
O :
pt is conscious , coherent , cooperative
Temp : 98 F
BP :120/90 mm hg.
PR : 92 bpm
RR : 22 cpm
Spo2: 97 % at RA
GRBS : 77 mg /dl
I/O :1600/ 1150 ml
CVS : S1 , S2 heard
RS :BAE + , NVBS +
P/A : soft , non tender
CNS : NAD
A :
Viral pyrexia under evaluation { thrombocytopenia ( resolving )( polyserositis - ascites ) }
Denovo DM 2
High output heart failure
? Wet beri beri with prerenal AKI ( resolving )
P :
- IV fluids 1 unit NS @ 75 ml / hr
- Tab . Dolo 650 mg PO / SOS
- plenty of oral fluids
- strict I/O charting
- Vitals monitoring 6 th hrly
- temperature charting 4 th hrly
- 2 egg whites per day
- Inj .HAI sc acc to GRBS
- GRBS 7 profile
- Inj thiamine 200 mg IV / BD in 100 ml NS
9/1/23
SOAP NOTES
Ward
Day 6
Unit 3
Dr.Nikitha (SR )
Dr.Vamshi Krishna ( PG 3 )
Dr. Nishitha ( PG 2 )
Dr.Govardhini Reddy ( PG 1 )
Dr. Meghana ( intern )
Dr. Tejarshini ( intern)
S : no fever spikes
Stools not passed ,no fever spikes , SOB decreased .
O :
pt is conscious , coherent , cooperative
Temp : 98 F
BP :120/70 mm hg.
PR : 92 bpm
RR : 20 cpm
Spo2: 98% at RA
GRBS : 78 mg /dl
I/O :1600/ 1150 ml
CVS : S1 , S2 heard
RS :BAE + , NVBS +
P/A : soft , non tender
CNS : NAD
A :
Viral pyrexia under evaluation { thrombocytopenia ( resolving )( polyserositis - ascites ) }
Denovo DM 2
High output heart failure , ? Wet beri beri with prerenal AKI ( resolving )
P :
- Inj thiamine 200 mg IV / BD in 100 ml NS
- syp lactulose 15 ml PO /HS
- plenty of oral fluids
- strict I/O charting
- Vitals monitoring 6 th hrly
- temperature charting 4 th hrly
- 2 egg whites per day
- Inj .HAI sc acc to GRBS
- GRBS 7 profile
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