MEDICINE CASE DISCUSSION
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CASE SCENARIO:
40 yr old male, post office employee, came to the casuality with complaints of
Fever since 10 days
Dry Cough since 6 days
Loose stools since 6 days
Burning Micturition since 6 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 7 days back, then he had
Fever which was low grade, intermittent, not associated with chills and rigor, relieved on medication.
Dry cough since 3 days w/o diurnal variation.
Loose stools (10-12 times) since 3 days, watery in consistensy, non foul smelling, not associated with any blood/ mucous/ pain abdomen/ tenesmus
Associated with burning micturation
no h/o decreased urine output/ vomitings/ chest pain/ palpitations/ pedal edema
He was admitted in a hospital till 3 days ago, was discharged yesterday and then was brought to our hospital.
3 days ago, according to outside report's
His Hb= 12.6
WBC= 1,900
platelets= 67,000
Normocytic Hypochromic RBCs
CUE = 8-10 / HPF pus cells
He was not reactive for MP
Not reactive for NS1 Antigen
PAST HISTORY:
K/C/O Asthma since 20 years for which he is taking ayurvedic medication.
Asthma worsens during winter season / cold enviroment.
No h/o his condition causing inability to perform his daily chores.
Not a k/c/o DM, HTN, TB, Epilepsy, Thyroid disorders
PERSONAL HISTORY:
Married
Occupation: post office employee
Appetite: normal
Diet: mixed
Sleep: reduced
Bladder and bowel movements: irregular, 5-6 episodes of loose stools/day. c/o burning micturition.
Addictions: none
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
The patient was c/c/c
Moderately built and nourished
No Pallor, icterus, cyanosis, clubbing, lymphadenopathy
Temp: 104°F
BP: 120/80 mm Hg
PR: 104/min
RR: 18 cpm
GRBS: 111 mg/dl
Spo2: 98 % on RA
SYSTEMIC EXAMINATION:
CVS :
S1S2 HEARD
no thrills no murmurs
P/A:
Non distended
Diffuse tenderness absent
Guarding and rigidity absent
CNS:
Patient is Conscious
Speech: normal
No signs of Meningeal irritation
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
INVESTIGATIONS:
— ECG
— USG abdomen
— Chest xray
— Hemogram, blood grouping, Rh typing
Day zero:
Day one:
Day two:
— RFT, LFT, RBS
PROVISIONAL DIAGNOSIS: Viral Pyrexia
?CAP ? UTI
TREATMENT:
Day zero:
1) Inj. CEFTRIAXONE 1gm/IV/BD
2) INJ. METRONIDAZOLE 100ml/IV/TID
3) Tab. AZITHROMYCIN 500 mg/PO/OD
4) Inj. PAN 40 mg/IV/OD
5) Inj. NEOMOL 1 gm/IV if temp >102°F
6) Tab. DOLO 650 mg/PO/TID
7) IVF 1.NS, 1.RL @75ml/hr
8) Tab. SPOLORAC DS/ PO/TID
9) Syp. ASCORIL-D 10ml PO/TID
10) Temp charting 2nd hrly and tepid sponging
11) BP/PR/GRBS/ Temp charting 4th hrly
Day one:
1) Inj. CEFTRIAXONE 1gm/IV/BD
2) INJ. METRONIDAZOLE 100ml/IV/TID
3) Tab. AZITHROMYCIN 500 mg/PO/OD
4) Inj. PAN 40 mg/IV/OD
5) Inj. NEOMOL 1 gm/IV if temp >102°F
6) Tab. DOLO 650 mg/PO/TID
7) IVF 1.NS, 1.RL @75ml/hr
8) Tab. SPOLORAC DS/ PO/TID
9) Syp. ASCORIL-D 10ml PO/TID
10) Temp charting 2nd hrly and tepid sponging
11) BP/PR/GRBS/ Temp charting 4th hrly
Day two:
1) Inj. CEFTRIAXONE 1gm/IV/BD
2) INJ. METRONIDAZOLE 100ml/IV/TID
3) Tab. AZITHROMYCIN 500 mg/PO/OD
4) Inj. PAN 40 mg/IV/OD
5) Inj. NEOMOL 1 gm/IV if temp >102°F
6) Tab. DOLO 650 mg/PO/TID
7) IVF 1.NS, 1.RL @75ml/hr
8) Tab. SPOLORAC DS/ PO/TID
9) Syp. ASCORIL-D 10ml PO/TID
10) Temp charting 2nd hrly and tepid sponging
11) BP/PR/GRBS/ Temp charting 4th hrly
COURSE IN THE HOSPITAL:
40 yr old male came to the opd with c/o fever since 10 days along with dry cough, loose stools, burning micturition since 6 days. The patient was managed conservatively. With improvement in overall condition and resolution of above mentioned symptoms pt was discharged and advised for follow up after 1 week
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