LONG CASE: A 53 yr old Male with Fever & Constipation.
January18,2023
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19/01/23:
A 53 yr old male patient of daily worker by occupation came to OPD on 18/01/2023.
Cheif complaint:
patient came to opd with a cheif complaint of fever since 4 days
C/o no passage of stools since 4days
C/o Abdominal discomfort&bloating since 4days
History of present illness:
Patient was apparently asymptomatic 4 days back then he developed fever high grade,intermittent associated with chills,rigors and headache and constipation,complaining of abdominal discomfort and bloating since 4 days
C/o loss of appetite
H/o burning micturation
H/o shortness of breath
No h/o vomitings ,cough,cold
No h/o abdominal pain
No aggravating factors relieved by medication,no diurnal variation.
Past history:
H/o Diabetes mellitus since 10yrs on regular medication (metformin,glimipiride)
Not k/c/o Hypertension, Asthma, epilepsy, CKD,thyroid.
Known alcoholic since 20 years (regular)
Stopped smoking 4 yrs back.
Personal history:
Diet:mixed
Appetite:loss
Sleep:Adequate
Micturation:present(burning)
Bowel &bladder movements:Irregular(since 4 days)
Addictions:alcoholic
Family history:
No relevant family history
Drug history:
No known history of drug allergy
General examination:
Patient is conscious, coherent and cooperative. Well oriented to time, place and person.
Moderately built and moderately nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy.
Pitting edema present in lowerlimbs
Vitals:
Temp- 101°F
BP-140/80MMHG
RR-18CPM
PR- 92BPM.
GRBS-167mg/dl.
Spo2 - 92%
Systemic examination:
Cardiovascular system:
Thrills: No
Cardiac sounds:S1S2 positive
Cardiac murmurs:No
Respiratory system:
Position of trachea:Central
Breath sounds:Vesicular
Dyspnoea:present
Wheeze:no
Adventitious sounds: Negative
On inspection:
Abdomen
Shape of abdomen: Scaphoid
Tenderness:No
Palpable mass:No
Umbilicus inverted
No scars and sinuses present
Henias orifices:Normal
Free fluid:No
Bruits:No
Liver: not Palpable
Spleen :Not palpable
Bowel sounds: Yes
Central Nervous system:
Pt is conscious,coherent, co-operatively oriented to time and place.
Speech: Normal
On palpation:
No rebound tenderness, no gaurding, no rigidity
No organomegaly
On percussion:
No fluid thrill
No shifting dullness
On Auscultation:
Bowel sounds normal
Investigations:
Chest x-ray:
Diagnosis:
Viral pyrexia with Thrombocytopenia
Treatment:
On 18/01/23
Inj.pan40mg OD
Inj.optineuron 1ampOD
Inj.thiamine1amp BD
Inj.lacix 40mg
T.dolo 650mg
Inj.neomol 1g
Inj.pan40mg OD
Inj.optineuron 1ampOD
Inj.thiamine200mg BD
Inj.lacix 40mg
T.dolo 650mg
Inj.neomol 1gm
Inj.kcl in 500ml Ns 1amp
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