Case history-11






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Date of Admission-

20-12-2021

A _27_ year old male patient  presented to OPD with chief complaints of    Fever  since  4_days


HISTORY OF PRESENT ILLNESS

Patient was apparently asymptotic  1 week back .

He  developed fever 4 days back which is high grade and continuous in onset with severe headache.

He then referred to local hospital which is not subsided after taking medication 

Patient is suffering with body pains from past 2 days


No history of vomitings ,loose stools 

No history of giddiness 

No history of skin rashes and bleeding manifestation



HISTORY OF PAST ILLNESS 

No history of  hypertension ,no abnormal palpatitation

No history of surgery, asthma, TB, CAD, epilepsy.

No history of chest pain


PERSONAL HISTORY


Diet:mixed

Appetite: no loss of appetite 

Bowel and bladder: normal 

Sleep  :inadequate 

Addiction: no addiction 



FAMILY HISTORY


No  similar complaint history of DM, CAD, Asthma and thyroid disorders in the family




GENRAL EXAMINATION 


Patient is conscious, coherent, co-operative.

No pallor,no icterus,no lymphadenopathy,no clubbing 

No Dehydration 

No odema



VITALS


Temperature- afebrile 


Pulse rate-  105bpm


Respiratory rate - 16 cycles/ min


BP- 100/80 mm/hg



SYSTEMIC EXAMINATION:


Cardiovascular System


chest wall is bilateral systemically 

Palpation -normal 

Auscultation-normal with regular heart bea


Cardiac sounds- S1, S2 heard




RESPIRATORY SYSTEM


Position of trachea- central


Breath sounds- vesicular


Adventitious sounds- No


 


ABDOMEN


Shape of abdomen- scaphoid


Mild tenderness


Palpable mass- not seen


Hernias orifices- not seen


Free fluid- mild



Liver- Not palpable


Spleen- Not palpable


Bowel sound- Yes




CENTRAL NERVOUS SYSTEM 


Patient is conscious 


Speech- normal


No sign of meningitis 


Motor and sensory system- Normal


Cranial nerves- intact




Investigation :








TREATMENT

Iv fluids 75 ml per hr 

Temperature charting hourly checked

Pcm 650 mg four times 

Mvt once daily 

Pantop 40 mg 

PR ,BP ,spo2 2 hrly monitoring

Look for orthostatic hypotension, bleeding manifestations

Tab doxycycline 100mg 2 times daily

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