32y male fever since 10 days ,productive cough since 5 days
A 32 year old male who is a village revenue assistant by occupation came to opd with c/o
Fever since 10 days
Productive cough since 5 days
HOPI:
Patient was apparently asymptomatic 10 days ago then he developed fever which is low grade , intermittent type, Mainly during night time and relived temporarily with medication , associated with chills and rigors.
C/o productive cough with mucoid sputum, intermittent type, which is mainly during night time.
-Generalised weakness present
-Not associated with burning micturition ,cold,rash ,body pains ,vomitings,loose stools
-Associated with sob on doing ordinary activity( grade 2 mmrc) since 5 days , relieves on taking rest
Past history:
Not a k/c/o DM,HTN ,CVA,CAD ,ASTHMA
Patient had a trauma history 5 years back his leg was injured totally, bandage applied for it
He is know case of HIV (diagnosed 1 year ago )and he is on medication
Personal history :
Diet-mixed
Appetite-normal
Sleep-adequate
B and bladder movements-normal
Addictions-toddy -12 years back ,occasionally
Daily routine -
The patient is a village revenue assistant by occupation.He wakes up by 7 am freshens up and takes his breakfast at 8:00am and goes to his work,Then he takes lunch break at 1pm and goes back to work ,he takes dinner by 8 pm and sits with his children for some time the goes to sleep at 9pm.
His daily activities are disturbed. Due to his symptoms
GENERAL EXAMINATION:
-No palor
-No Icterus
-No cyanosis
-No lymphadenopathy
-No edema
-No clubbing of fingers
Temperature:
Febrile - 99.9°F
Pulse: 82 beats per minute
Respiratory rate: —16 cycles per minute
Blood pressure: 130/90 mm of Hg
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 present
Respiratory system:
Bilateral airway entry present ,crepts heard in IAA ,left ISA ,Right IAA
Abdomen:
shape scaphoid
umbilicus central , inverted
no increase in local temp,no tenderness
No spleenomegaly
No hepatomegaly
BS+
Investigations:
Diagnosis:
Pyrexia under evaluation
?pulmonary Tb
? community acquired pneumonia
03/08, 1:15 pm
Date of admission:2/08/23
Ward patient
Dr.Rakesh Biswas(HOD)
Dr.Zain Alam(SR)
Dr.Narsimha Reddy(PGY2)
Dr.Lohith Varma(PGY1)
S : c/o High grade fever since 10 days
Productive cough since 5 days
O:
Patient is conscious coherent and cooperative
No pallor, icterus , clubbing, cyanosis, lymphadenopathy,
Vitals :
BP- 140/100mmHg
PR -83bpm
RR-18 cpm
Temperature - 101°c
CVS: s1,s2 heard, no Murmurs
RS: BAE+,NVBS
P/A: soft, nontender, No organomegaly
CNS:NFND , NHMF
A: Pyrexia under evaluation
P:
1)Inj Neomol 1 gm /iv/sos
2)Tab Dolo 650 mg/po/sos
3)syp Ascoril -D po/TID
4/08/23
Date of admission:2/08/23
Ward patient
Dr.Rakesh Biswas(HOD)
Dr.Zain Alam(SR)
Dr.Narsimha Reddy(PGY2)
Dr.Lohith Varma(PGY1)
S : c/o High grade fever since 10 days
Productive cough since 5 days
O:
Patient is conscious coherent and cooperative
No pallor, icterus , clubbing, cyanosis, lymphadenopathy,
Vitals :
BP- 140/100mmHg
PR -83bpm
RR-18 cpm
Temperature - 101°c
CVS: s1,s2 heard, no Murmurs
RS: BAE+, bilateral crepts present in IAA ,left ISA ,right IAA
P/A: soft, nontender, No organomegaly
CNS:NFND , NHMF
A: Pyrexia under evaluation ? Since 10 days ? CAP?pulm tb
P:
1)Inj Neomol 1 gm /iv/sos
2)Tab Dolo 650 mg/po/sos
3)syp Ascoril -D po/TID
5/08/23
Date of admission:2/08/23
Ward patient
Dr.Rakesh Biswas(HOD)
Dr.Zain Alam(SR)
Dr.Narsimha Reddy(PGY2)
Dr.Lohith Varma(PGY1)
S : c/o productive cough
And body pains
O:
Patient is conscious coherent and cooperative
No pallor, icterus , clubbing, cyanosis, lymphadenopathy,
Vitals :
BP- 120/80 mmHg
PR -78 bpm
RR-18 cpm
Temperature - 99 F
CVS: s1,s2 heard, no Murmurs
RS: BLAE+, crepts present in Right IAA
P/A: soft, nontender, No organomegaly
CNS:NFND , NHMF
A: Pyrexia under evaluation ? Since 10 days ? CAP?pulm tb
K/c/o Retroviral disease since 1 year
P:
1)Inj Neomol 1 gm /iv/sos
2)Tab Azithromycin 500 mg /po/of /8am
3)Tab Dolo 650 mg/po/TID
4)syp Ascoryl -Ls po/TID
5)Tab Dolutegravir (50mg) + Lamivudine (300mg)+Tenofovir(300mg) po/Hs/9 pm
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