A 50 year old male ....

50 YR OLD MALE WITH FEVER AND BODY PAINS SINCE 5 DAYS

A 50 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 

GEN 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 












 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 
USG Abdomen 
Chest X Ray 
CUE 
RBS 
LFT

RFT 
Hemogram 

PROVISIONAL DIAGNOSIS:
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  

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