A 55YR OLD MALE PATIENT CAME TO THE CASUALTY WITH C/O FEVER SINCE 15DAYS



 


A 55yr old male patient came to the casualty with C/o fever since 15days .


HOPI-

Patient was apparently asymptomatic 15days ago then he developed high grade fever , a/w chills and rigors,evening rise of temperature , relieves on medication , a/w back pain , joint pains (elbow ,knee) since 10days .

C/o generalised weakness since 10days 

C/o urinary incontinence since 10days 

No c/o vomitings , loose stools , pain abdomen , burning micturition .


Not a k/c/o HTN, DM , TB, Asthma , CAD , Epilepsy.


Family history - insignificant 


Personal history - 

Diet - mixed 

Appetite - normal 

Bowel movements - regular 

Bladder - c/o urinary incontinence since 10days 

Addictions - 

Regular alcohol intake since 30yrs 

Smoker since 30yrs .


GENERAL EXAMINATION

Patient is c/c/c 

Pallor +ve 

No icterus, cyanosis , clubbing , lymphadenopathy , edema 




VITALS 

Temp - 100.6 °F

BP - 100/80 mm Hg 

PR - 85bpm

RR - 16cpm

RBS - 144 mg/dl

SpO2 - 99% @ RA 


SYSTEMIC EXAMINATION 

CVS - S1 S2 + , no murmurs 

RS - NVBS + , BAE + 

P/A - soft , non tender , BS +

CNS - NAD 


PROVISIONAL DIAGNOSIS 

Viral pyrexia ( Resolved ) with viral Arthralgia and Neuropathy with Dextrocardia with resolved liver abcess with urinary Incontinence secondary to? BPH


Investigations


2D Echo

ECG

13/12/21


15/12/21


Soap notes 
16/12/21 

55/M 

S - No fever spikes 

O- Pt is c/c/c 

      Temp - Afebrile 
      BP -80/50Mmhg 
      PR - 82bpm 
      CVS -s1s2 + 
      CNS - NAD 
      RS - NVBS 
     P/A - soft non tender 

A - viral pyrexia ( Resolved ) with viral Arthralgia and Neuropathy with Dextrocardia with resolved liver abcess with urinary Incontinence secondary to? BPH 

P- INJ THIAMINE 1AMP IN 100ml NS IV/TID 

INJ PCM 500MG PO/TID 

TAB . NAPROXEN 250MG PO/BD

TAB . ULTRACET 1/2 PO/ QID 

TAB . PANTOP 40MG PO/OD 

TAB .LASIX 20MG PO/BD

HIGH PROTEIN DIET 

2 EGG WHITES / DAY 

GRBS 12Th HOURLY


Soap notes 
17/12/21 

55/M 

S - No fever spikes 

O- Pt is c/c/c 
      Temp - Afebrile 
      BP -90/60mmhg 
      PR - 74bpm 
      CVS -s1s2 + 
      CNS - NAD 
      RS - NVBS 
     P/A - soft non tender 

A - viral pyrexia ( Resolved ) with viral Arthralgia and Neuropathy with Dextrocardia with resolved liver abcess with urinary Incontinence secondary to? BPH 

P- 
1. Tab.THIAMINE 100mg PO/BD 
2. Tab PCM 500MG PO SOS
3. TAB . NAPROXEN 250MG PO/BD
4. TAB . ULTRACET 1/2 PO/ QID 
TAB .LASIX 20MG PO/BD (if SBP >110mmHG)
5. TAB. TAMSULOSIN -D 0.4MG PO/HS 
6. HIGH PROTEIN diet
2 EGG WHITES / DAY




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