Case history 7

CASE HISTORY 7

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A 45 years old male patient presented to the opd with chief complaints of : 

fever with chills since 4 days 

HISTORY OF PRESENT ILLNESS:

         patient is apparently well 4 days back with his daily work like farming and then he developed fever with chills where he cannot do his work he went the near by hospital and given medication subsided temporarily and suggested to a big hospital for further treatment .

He also complains of generalised body pains and headache 

PAST HISTORY  : 

         patient has no similar history in the past . And

No history of diabetes

No history of hypertension 

No history of asthma

No history of cold 

No history of cough

No history of vomiting or loose stools

PERSONAL HISTORY  : 

  

     appetite                : normal 

      Diet                       : normal

Bowel and bladder : normal 

Micturition               : normal 

Addictions                 : takes alcohol occasionally 

FAMILY HISTORY  : 

     

         there are no similar complaints in the family members 

TREATMENT HISTORY : 

   

       patient took medication for fever which is given by the local doctor in which the fever subsided temporarily. 

GENERAL EXAMINATION  : 

         Patient is conscious,  coherent , and patient consent is taken and well oriented to time and place 

And examined in a well lit room 

Patient is moderately built and moderately nourished

Pallor not seen 

Cyanosis not seen 

Lymphadenopathy not seen 

Pedal edema not seen

Icterus not seen

Clubbing not seen

VITALS  : 

Temperature        :   98.8 ° F

Blood pressure    :   130 / 90

Pulse rate              :   70

Respiratory rate   :   18 

SPO2                       :  98 % of room air 

SYSTEMIC EXAMINATION  : 

RS       :  BAE is positive 

CVS    :   S1 and S2 are heard 

CNS   :   NAD 

PA      :  soft and non tender 

INVESTIGATIONS  : 

CUE : 

TPR  graphic sheet : 

GLYCATED HEMOGLOBIN  : 

 Blood sugar random 

Hemogram : 

ULTRASOUND  : 

TREATMENT  :  

              

INJ  taxim   1g  iv / bd 

IVF  NS , RL 100 ml per hour

INJ pantop 40 mg po/ od 

INJ optineuron 1 amp in 100 ml  NS / IV / OD 

TAB PCM  650 mg  po  / bd

Temperature,  BP , PR , monitoring 4th hourly

Plenty of oral fluids 

Strict I / o charting 

PROVISIONAL DIAGNOSIS : 

                     Viral pyrexia with thrombocytopenia