CASE -7

A 65 year old patient of farmer in occupation and resident of miriyalaguda came to the hospital with complaints  of fever, generalized weakness since 15 days and pain during swallowing since 3 days from which he came to hospital

HOPI:
Patient was apparently asymptomatic 15 days back then developed fever, insidious in onset, gradually progressive, high grade, intermittent associated with chills and rigours associated with generalised body pains 

C/o vomitings- 1 episode, bilious, food as content non blood stained, non projectile. 

H/o burning micturition 15 days back 

No dysuria, frequency, urgency, hesitancy 
No history of epigastric pain
NO H/O CONSTIPATION.

PAST HISTORY:
 There was a history of pedal edema 15days back along with decreased urine output for which he was treated in hospital and was treated with antibiotics (piptaz for 5 days) following which both are resolved.
NO H/O TB ,ASTHAMA, EPILEPSY, THYROID DISORDERS,BLOOD TRANSFUSIONS,DM,HTN
 
PERSONAL HISTORY:
Diet:  mixed
Sleep: regular 
No loss of Appetite
Bowel movements are regular 
No Addictions

Family history-  insignificant 

General examination::
Patient is conscious,cohorent , cooperative well known with time, place, person 
He is well built and moderately nourish
Pallor- Absent 
Icterus: Absent 
Cyanosis: Absent 
Clubbing: Absent 
Lymphadenopathy: absent 
No pedal oedema
VITALS:
TEMP:97.1F
PR- 86bpm
RR:18cpm
BP:120/80mm hg
Spo2: 98%
SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Patient examined in sitting position
Inspection:-
Upper respiratory tract - oral cavity, nose & oropharynx appear normal. 

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear equal on both sides.

Trachea central in position & Nipples are in 5th Intercoastal space

No dilated veins,sinuses, visible pulsations.

Trachea central in position

BREATH SOUNDS:
Vocal fremitus was noted 
Normal vesicular breath sounds were noted.

CVS EXAMINATION:
S1 AND S 2 HEARD
No cardiac murmurs
Apex beat is palpable at 5 th intercostal space

ABDOMEN EXAMINATION:
INSPECTION:

SHAPE OF THE ABDOMEN: OBESE

No tenderness
Palpation:
No palpable mass
Liver is palpable 
Spleen is not palpable

ASCULTATION:

BOWEL SOUNDS RE NORMAL
 
PROBISIONAL DIAGNOSIS:
Left pyelonephritis with mild Hepatomegaly

INVESTIGATIONS:





TREATMENT:
Inj neomol 1gm IV/SOS

Inj piptaz 4.5gm iv TID

Tab Pan 40mg po/od

Tab Pcm 650mg PO/TID 

Betadine gargles BD


 





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