73 yr male with fever
Case:
73 yr male came with chief complaints of
- Fever since 7 days
- Cough since 7 days
-SOB since 7 days
HOPI:
-Patient was apparently asymptomatic 7 days ago then he developed fever which is intermittent,high grade associated with body pains
- Cough since 7 days associated with expectoration,no haemoptysis
-SOB since 7 days ,grade 2
- No history of vomiting,loose stools,orthopnea,PND
Past history:
K/C/O HTN since 8 yrs on Telma 40 mg
N/K/C/O DM,Asthma, epilepsy,CVA,CAD
Patient has history of snake bite 30 yrs ago after which he developed hypopigmented patches on both lower limbs and upper limbs
Present history:
Appetite -Normal
Diet- Mixed
Sleep -Adequate
Bowel and bladder habits -Regular
Addictions:Takes 10 beedis / day from 20 years
Chronic alcoholic from 20 years
General Examination:
Patient is conscious, coherent, co-operative
Well oriented to time, place and person
Moderately built and nourished
No pallor , icterus, cyanosis, clubbing, pedal oedema, lymphadenopathy
Vitals:
PR:88bpm
BP:100/60 mm hg
RR: 24cpm
Temp:97F
Systemic Examination:
CVS:S1S2 Present
RS:BAE Present,NVBS
P/A:Soft, Non tender
CNS:NAD
Investigations:
Provisional Diagnosis: Pyrexia under evaluation
Treatment:
1)INJ.FALCIGO 120 MG IV
2)T.DOXY 100 MG PO/BD
3)T.PCM 650 MG PO/TID
4)T.PAN 40MG PO/OD/BBF
5)IV FLUIDS 2 NS,1 RL @ 100 ML/HR
