fever projr unclassified 47/M 202402512
unclassified ; 20240126042
Diagnosis
VIRAL PYREXIA
HEART FAILURE WITH MIDRANGE EJECTION FRACTION[49%] SECONDARY TO CORANARY ARTERY DISEASE S/P PTCA 1 1/2 YEAR AGO
DIABETES MELLITUS SINCE 4 YRS
Case History and Clinical Findings
C/O FEVER SINCE 3 DAYS
C/O COUGH SINCE 3DAYS
C/O LOOSE STOOLS SINCE 3 DAYS
HOPI:
PATIENT WAS APPARENTLY ALRIGHT 3 DAYS BACK THEN HE HAD FEVER WHICH IDS HIGH GRADE ASSOCIATED WITH CHILLS AND RIGORS CONTINUOUS, RELIVED BY TAKING MEDICATION
COUGH SINCE 3DAYS ASSOCIATED WITH SPUTUM , YELLOWISH IN COLOR, NON BLOOD STAINED, MUCOID IN CONSISTENCY
C/O LOOSE STOOLS SINCE 3 DAYS YELLOWISH TO RED IN COLOR
NO PEDAL EDEMA
BURNING MICTURATION +
NO ABDOMINAL PAIN
PAST HISTORY:
K/C/O DM II SINCE 4 YEARS ON TAB METFORMIN 500MG PO OD
K/C/O CAD SINCE ON AND OFF ON
TAB TRIMETAZIDINE MR 35MG,
TAB DYTOR PO OD
TAB TELMA 40MG + METAPROLOLPO OD
TAB ECOSPRIN GOLD 20 PO HS
TAB EPLERENON 25 MG PO OD
PERSONAL HISTORY:
DIET:MIXED
SLEEP:ADEQUATE
BOWEL AND BLADDER: INCREASED SINCE 3 DAYS
ADDICTIONS: CIGARETTES 4 PER DAY REGULARLY, STOPPED DRINKING ALCOHOL SINCE 2 YEARS
APPETITE:NORMAL
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON.
NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA.
VITALS:
TEMPERATURE:103
BP:100/70 MM HG
PR:86 BPM REGULARLY IRREGULAR
RR:18 CPM
SYSTEMIC EXAMINATION:
CVS:S1,S2 HEARD NO MURMURS.
RS:BAE +,NO MURMURS
GRBS: 113MG%
SPO2: 92 ON ROOM AIR
PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY
CNS:NO FOCAL NEUROLOGICAL DEFICITS.
Investigation
HBsAg-RAPID 17-01-2024 10:49:AM Negative
Anti HCV Antibodies - RAPID 17-01-2024 10:49:AM Non Reactive
COMPLETE URINE EXAMINATION (CUE) 17-01-2024 10:49:AM
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN ++
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 5-6
EPITHELIAL CELLS 2-4
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS DEPOSITS Absent
OTHERS Nil
WIDAL TEST 17-01-2024 10:49:AM
S.typhi 'O' Antibodies No Agglutination seen
S.typhi 'H' Antibodies No Agglutination seen
S.PARATYPHI 'AH' ANTIBODY No Agglutination seen
S.PARATYPHI 'BH' ANTIBODY No Agglutination seen
BLOOD UREA 17-01-2024 10:49:AM 25 mg/dl 42-12 mg/dl
SERUM CREATININE 17-01-2024 10:49:AM 1.0 mg/dl 1.3-0.9 mg/dl
SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 17-01-2024 10:49:AM
SODIUM 139 mEq/L 145-136 mEq/L
POTASSIUM 3.8 mEq/L 5.1-3.5 mEq/L
CHLORIDE 105 mEq/L 98-107 mEq/L
CALCIUM IONIZED 1.18 mmol/L mmol/L
POST LUNCH BLOOD SUGAR 17-01-2024 10:50:AM 120 mg/dl 140-0 mg/dl
LIVER FUNCTION TEST (LFT) 17-01-2024 09:26:PM
Total Bilurubin 0.60 mg/dl 1-0 mg/dl
Direct Bilurubin 0.18 mg/dl 0.2-0.0 mg/dl
SGOT(AST) 18 IU/L 35-0 IU/L
SGPT(ALT) 16 IU/L 45-0 IU/L
ALKALINE PHOSPHATE 96 IU/L 128-53 IU/L
TOTAL PROTEINS 6.6 gm/dl 8.3-6.4 gm/dl
ALBUMIN 3.5 gm/dl 5.2-3.5 gm/dl
A/G RATIO 1.16
2D ECHO:
EF 49%
TRIVIAL TR+, NO MR/AR
RWMA +,M CAD HYPOKINETIC, NO AS/MS
MILD LV DYSFUNCTION
NO DIASTOLIC DYSFUNCTION
Treatment Given(Enter only Generic Name)
INJ MONOCEF 1GM IV BD
INJ DOXYCYCLINE 100MG IV BD
TAB PCM 650 MG PO SDOS
TAB ECOSPRIN GOLD 75/75/20 PO HS
TAB DYTOR PO OD
TAB TELMA 40MG + METOPROLOL 50 MG PO OD
TAB TRIMETAZIDINE MR 35 MG PO BD
TAB EPLERENONE 25MG PO OD
TAB METFORMIN 500MG PO OD
SYP GRILLINCTUS 10ML TID
TAB CEPODEM XD 325MG PO BD
TAB MONTAC LC PO
Advice at Discharge
TAB CEPODEM XP 325MG PO BD 1-X-1 FOR 5 DAYS
TAB DOXYCYCLINE 100MG BD 1-X-1 FOR 5 DAYS
TAB MONTAC LC PO HS X-X-1 FOR 5 DAYS
TAB PCM 650 MG PO SOS
TAB ECOSPRIN GOLD 75/75/20 PO HS X-X-1 CONTINUE
TAB DYTOR 10 MG PO OD X-1-X CONTINUE
TAB TELMA 40MG + METOPROLOL 50 MG PO OD 1-X-X CONTINUE
TAB TRIMETAZIDINE MR 35 MG PO BD 1-X-1 CONTINUE
TAB EPLERENONE 25MG PO OD X-1-X CONTINUE
TAB METFORMIN 500MG PO OD 1-X-X CONTINUE
SYP GRILLINCTUS 10ML TID
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