51 YR OLD MALE WITH FEVER AND VOMITINGS

356190 p mallesh
CASE HISTORY AND CLINICAL FINDINGS
C/O FEVER SINCE 3 DAYS
C/O VOMITINGS 2 DAYS BACK
HOPI
PT WAS APPARENTLY ASYMPTOMATIC 3 DAYS BACK THEN HE DEVELOPED HIGH GRADE
FEVER,CONTINUOUS, NO DIURUINAL VARIATION ASS WITH CHILLS RIGORS.ASS HEADACHE
, GENERALISED PAINS
NO H/O COUGH,COLD,THROAT PAIN
H/O EPISODES OF VOMITINGS,BIIOUS,NON PROJECTILE ON FIRST DAY FEVER
NO H/O PAIN ABDOMEN,HEMATURIA,ABDOMINAL DISTENSION
H/O SOB GRADE 2
H/O LOSS OF APPETITE
PAST HISTORY:
K/C/O DM SINCE 20 YRS ON GLYCOMET SR PO/OD
K/C/O HYPOTHYROIDISM SINCE 15 YRS ON THYRONORM 50 MCG
N/K/C/O CAD,CVA,ASTHMA,TB
GENERAL EXAMINATION
PT IS CCC
NO SIGNS OF PALLOR,CYANOSIS,CLUBBING,LYMPHADENOPATHY
PR 76 BPM
BP 130/80 MMHG
SPO2 98
RR 22 CPM
SYSTEMIC EXAMINATION:
CVS S1 S2 HEARD
RS BAE+
GIT SOFT NT
CNS NFND
INVESTIGATION
BLOOD UREA15-12-2023 06:13:PM3.3 mg/dl42-12 mg/dlSERUM CREATININE15-12-2023
06:13:PM1.4 mg/dl1.3-0.9 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED
CALCIUM 15-12-2023 06:13:PM SODIUM135 mEq/L145-136 mEq/LPOTASSIUM3.7 mEq/L5.1-3.5
mEq/LCHLORIDE98 mEq/L98-107 mEq/LCALCIUM IONIZED1.01 mmol/Lmmol/LCOMPLETE
URINE EXAMINATION (CUE) 15-12-2023 06:13:PM COLOURPale
yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN++++SUGARNilBILE
SALTSNilBILE PIGMENTSNilPUS CELLS3-6EPITHELIAL CELLS2-4RED BLOOD
CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilHBsAg-RAPID15-
12-2023 08:58:PMNegative Anti HCV Antibodies - RAPID15-12-2023 08:58:PMNon Reactive LIVER
FUNCTION TEST (LFT) 16-12-2023 07:37:AM Total Bilurubin1.25 mg/dl1-0 mg/dlDirect Bilurubin0.24
mg/dl0.2-0.0 mg/dlSGOT(AST)22 IU/L35-0 IU/LSGPT(ALT)13 IU/L45-0 IU/LALKALINE
PHOSPHATE135 IU/L128-53 IU/LTOTAL PROTEINS8.3 gm/dl8.3-6.4 gm/dlALBUMIN4.3 gm/dl5.2-
3.5 gm/dlA/G RATIO1.11POST LUNCH BLOOD SUGAR16-12-2023 08:38:AM124 mg/dl140-0
mg/dlT3, T4, TSH 16-12-2023 08:39:AM T30.44 ng/ml1.87-0.87 ng/mlT42.19 micro g/dl12.23-6.32
micro g/dlTSH1.42 micro Iu/ml5.36-0.34 micro Iu/mlPOST LUNCH BLOOD SUGAR16-12-2023
10:37:PM140 mg/dl140-0 mg/dlBLOOD UREA17-12-2023 06:23:AM30 mg/dl42-12 mg/dlSERUM
CREATININE17-12-2023 06:23:AM1.5 mg/dl1.3-0.9 mg/dlSERUM ELECTROLYTES (Na, K, C l)
AND SERUM IONIZED CALCIUM 17-12-2023 06:23:AM SODIUM138 mEq/L145-136
mEq/LPOTASSIUM4.1 mEq/L5.1-3.5 mEq/LCHLORIDE98 mEq/L98-107 mEq/LCALCIUM
IONIZED1.10 mmol/Lmmol/L
USG ABDOMEN :
MILD HEPATOMEAGLY
GRADE 1 FATTY LIVER
MIL SPLENOMEAGLY
DIAGNOSIS
VIRAL PYREXIA WITH BICYTOPENIA WITH ACUTE GASTROENTRITIS
K/C/O HYPOTHYROIDISM SINCE 15 YEARS
K/C/O DM II SINCE 20 YRS
TREATMENT GIVEN
INJ NEOMOL 1 GM IV/STAT
INJ CEFTRIAXONE 2GM IV/BD
INJ PAN 40 MG IV/OD
INJ ZOFER 4MG IV SOSTAB PCM 650 MG PO/TIDTAB THYRONORM 50 MCG PO/ODTAB
METFORMIN 500 MG /PO/ODCAP DOXYCYCLINE 100 MG PO/BDTAB SPOROLAC PO/TID
Advice at Discharge
CAP DOXYCYCLINE 100 MG PO/BD 2 DAYSTAB PCM 650 MG PO/SOSTAB THYRONORM 50
MCG PO/ODTAB METFORMIN 500 MG /PO/OD


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