40yrs male with fever and pain abdomen
N.sahithi
ROLL NO: 96
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40yrs old male patient admitted on 18/10/21 with fever and headache since 15days and pain abdomen since 10days and loss of appetite since 1week . Blood in stools since morning.
Daily routine:
He wakes up at 5 am in the morning and goes to work in the farm by 7 he produces millets in farm and feeding 4 cows. .Has his lunch in the farm and returns home in the evening ,eats his dinner and sleeps by 10 pm.
He gives history of spraying pesticides in his farm of 10acres 20days back. He mentioned about the insects in the farm.
History of present illness:
C/o Headache diffuse type non radiating not associated with diminished or blurring of vision.
C/o Blood in stools since morning fresh blood not mixed in stools.
Past history:
No Similar complaints in past.
History of haemorrhoids 1yr back . Blood in stools and relieved on medication.
Not a known case of dm, htn,asthma,tb,epilepsy.
Personal history:
Diet:mixed
Appetite:Decreased
Sleep:adequate
Bowel and bladder: normal.
Allergies: no
Addictions: alcoholic.
Family history:
Not Significant.
General examination:
Patient is conscious coherent co operative oriented to time,place,person.
Pallor: absent
Icterus no
Cyanosis no
Clubbing no
Lymphadenopathy no
Edema no
Vitals:18/10/21
Pulse rate 78bpm, regular , normal volume.
Blood pressure 170/90 mm/Hg
Respiratory rate18 cpm
Temperature afebrile
Systemic examination:
CVS:S1 and S2 heart sounds heard.
No murmurs heard
RESPIRATORY SYSTEM
Position of the trachea central
BAE present , vesicular breath sounds heard
Abdomen examination:
On inspection shape of the abdomen is scaphoid
Tenderness in umbilical region.
CNS
Patient is conscious, coherent , oriented to place , time , person .
Investigations:
Hemogram:17/10/21
Urine examination:17/10/21
Dengue test:
HIV:
Hepatitis B:
Hepatitis C:
Urine protein and creatinine:
Hemogram:19/10/21:
Stool for occult blood:
Colour doppler 2D echo:
Usg. Abdomen:
CRP :
Rheumatoid factor:
ESR:
Hemogram:20/10/21:
Treatment (18/10/21):
Ivf ns,RL @100/ hrInj neomol l00ml / iv if fever > 101.01FInj pantop 40ml iv odInj Zofer 4mg iv sos Tab dolo650mg po TIDTabDOXYCYCLINE 100mg po bd Inj optineuron 1amp in 100ml ns iv Monitor vitals 4hrly .
Vitals(19/10/21):
Pulse rate 89bpm ,Regular , normal volume.
Blood pressure 130/90 mm/Hg
Respiratory rate 20 cpm
GRBS: 140mg/dl
Temperature: 98.4F
Treatment (19/10/21):
Ivf ns,RL @100/ hrInj neomol l00ml / iv if fever > 101.01FInj pantop 40ml iv odInj Zofer 4mg iv sos Tab dolo650mg po TIDTabDOXYCYCLINE 100mg po bd Inj FALCIGO iv at 0, 12, 24,48.Inj optineuron 1amp in 100ml ns iv Monitor vitals 4hrly .
Vitals(20/10/21):
2 episodes of spikesHeadache ( diffuse type)
Pulse rate 72bpm ,Regular , normal volume.
Blood pressure 130/90 mm/Hg
Respiratory rate 24 cpm
Temperature: 98.6F
GRBS: 108mg/dl
Pulse rate 72bpm ,Regular , normal volume.
Blood pressure 130/90 mm/Hg
Respiratory rate 24 cpm
Temperature: 98.6F
GRBS: 108mg/dl
Treatment (20/10/21):
Ivf ns,RL @100/ hrInj neomol l00ml / iv if fever > 101.01FInj pantop 40ml iv odInj Zofer 4mg iv sos Tab dolo650mg po TIDTabDOXYCYCLINE 100mg po bd Inj FALCIGO iv at 0, 12, 24,48.Inj optineuron 1amp in 100ml ns iv Syp lactulose 10ml Inj ceftriaxone iv Monitor vitals 4hrly .
Vitals(21/10/21):
Pulse rate 76bpm ,Regular , normal volume.
Blood pressure 100/70 mm/Hg
Respiratory rate 22cpm
Temperature: 98.6F
GRBS: 107mg/dl
Pulse rate 76bpm ,Regular , normal volume.
Blood pressure 100/70 mm/Hg
Respiratory rate 22cpm
Temperature: 98.6F
GRBS: 107mg/dl
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