Case of 47 year old male, came to opd with body pains and fever

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A 67 yr old male patient came to the causality with chief complaints of 

- fever since 10 days 

- body pains and generalized weakness since 10 days 

- shortness of breath since 5 days 

- abdominal pain since 2 days 

History of presenting illness

Patient was apparantly asymptomatic 10 days back later he developed fever associated with chills with evening of rise of temperature . 


- fever since 10 days 

- body pains and generalized weakness since 10 days 

- shortness of breath since 5 days 

- abdominal pain since 2 days 

History of presenting illness

Patient was apparantly asymptomatic 10 days back later he developed fever associated with chills with evening of rise of temperature .

 /o dry cough , generalized weakness and body pains . 

H/o  vomiting on 4th day of illness had food particles as content which was no bilious and non projectile.

H/o breathlessness in exertion since 5 days 

H/o epigastric pain since 4 days  

H/o abdominal pain since 2 days


PAST HISTORY :

-In 2007; he underwent Surgery for Aortic dissection.

 -And after 10 months Underwent ESWL for kidney stones in Right Kidney.

-H/O Hypertension since 15 years.

-No H/O Diabetes;Asthma;Tuberculosis;Epilepsy.


PERSONAL HISTORY :

-He wakes up at 5:00 am 

-Eat's meal for 3 times a day and had good appetite and 

-Has adequate sleep and 

-Bowel - regular 

-H/O burning micturition since 10 days. 

-No addictions.


FAMILY HISTORY:

No similar complaints in any one of his family members. 


GENERAL EXAMINATION:

Patient is Conscious; Coherent and Cooperative and Well oriented to time;place and person. 



Pallor                                            - Absent 

Icterus                                          - Present 

Clubbing                                      - Absent 

Kolinychia                                    -Absent

Generalised Lymphadenopathy -Absent 

Bilateral Pedal Edema                 -




Pulse Rate          -   102 bpm

Blood pressure   -  90/60 mm of Hg

Respiratory Rate - 26cpm

SpO2                     - 97%

GRBS                     - 150mg/dl





SYSTEMIC EXAMINATION:


ABDOMEN EXAMINATION:


INSPECTION:

Shape of abdomen- distended 

Engorged veins       -Absent


PALPATION:

No rise of temperature 

 Epigastric tenderness 

No palpable mases

No hepatomegaly

No splenomegaly 

 

PERCUSSION:

normal liver span


ASCULTATION :

bowel sounds heard




Respiratory system;

-Shape of the chest normal, 


Llongitudinal Scar is present over the sternum.


-Trachea appears to be in centre 


-Normal vesicular breath sounds heard 


Cardiovascular system;

- S1 S2 heard 

- No murmors


CNS EXAMINATION 

- pateint is conscious 

- speech normal 


INVESTIGATION










USG 

 
I
Provisional diagnosis
 Urinary tract infection ?
Treatment:
Iv 20NS 20 RL @75ml /hr 
- Inj pan 
- Inj ceftriaxone  
- Tab dolo 


As per today: follow up:

Thrombophlebitis is observed 


Murmur grade 1 heard 

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