70/M with fever and dysphaga under evaluation

 Unit 4 admission 

AMC 5th bed 

70 yr old male, farmer by occupation, resident of nalgonda, came to casualty with complaints of fever since 2 weeks, loss of appetite since 2 weeks, generalised weakness since 2 weeks, vomitings since 1 week and nausea since 1 week.

Patient was apparently asymptomatic 2 weeks back, then developed fever which is insidious in onset, gradually progressive and associated with chills and rigors, subsided on taking medication.

C/o vomitings since 1 week bilious in type, non projectile, 2 episodes in a day, not associated with pain abdomen

C/o nausea and generalised weakness 

Not a k/c/o DM, HTN, thyroid disorders, epilepsy, asthma, CVA 

8 years back he had h/o deviation of mouth and visited an hospital ? CVA , medication not known 

On examination 

Patient is conscious, coherent, cooperative 

No Pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema 

Temp- 98.5 F

BP - 130/90 mmhg 

PR - 112 bpm 

RR - 18 cpm

SpO2 - 92% at RA

GRBS - 115 mg/dl 

CVS - S1, S2 heard 

RS - BAE +, NVBS heard 

CNS - NFND 

P/A - Soft , BS + 

Provisional Diagnosis : Fever under evaluation 

Dysphagia under evaluation

Investigations: 

ECG:

X- RAY: 

Hemogram 

Hb - 12.5 gm/dl

TLC - 3400 

PCV - 38.7 

RBC - 4.4 million/cumm 

PLT - 2.1 lakh 

Blood grouping and typing- B positive 

RBS - 98 mg/dl 

LFT 

TB - 2.65

DB - 0.72

AST - 24

ALT - 29 

ALP - 144

TP - 7.7 

RFT 

Urea - 116

Uric acid - 10.6 

Sr. Creatinine- 1.1 

Sr. Na - 140

Sr. K - 4.6 

Sr. Cl - 98 

Serology ( HCV, HIV, HbsAg ) - negative 

Malaria - negative 

Dengue serology - negative

Treatment: 

On 4/11/21:

1. IVF - NS,RL @ 75ML/HR

2. INJ. PANTOP 40 MG IV OD

3. INJ. ZOFER 4 MG IV OD

4. INJ. NEOMOL 100ML IV IF TEMP IS GREATER THAN 101.1F

5. TAB. PCM 650MG PO SOS

6. WATCH FOR BLEEDING MANIFESTATIONS

7. BP, PR, SPO2 MONITORING 2ND HRLY

8. INJ. OPTINEURON 1AMP IN 100ML NS IV OD

ON 5/11/21:

UNIT 4

70/M  AMC 

S: 

No fever spikes, vomitings subsided, decreased appetite, no pain abdomen, difficulty in swallowing solid food, drinking fluids, weight loss since 20 days.

O:

Pt is c/c/c

Temp: afebrile

BP: 90/70 mm hg

PR: 94 bpm

CVS : S1S2+ no murmurs

RS: NVBS+ NO CREPTS

P/A : SOFT, NON TENDER

SPO2: 98% @ RA

RR : 18 CPM

A:

FEVER UNDER EVALUATION

DYSPHAGIA UNDER EVALUATION

P:

1. IVF - NS, RL @75 ML/ HR

2. INJ.PANTOP 40MG IV OD

3. INJ. OPTINEURON 1AMP IN 100 ML NS IV OD

4. INJ. ZOFER 4 MG IV BD

5. INJ. NEOMAL 100 ML IV IF TEMP GREATER THAN 101.1F

6. TAB.PCM 650 MG PO SOS

7. MONITOR VITALS 2ND HRLY

ENT REFERRAL: ON 5/11/21

USG - abdomen: