UNIT 2 ADMISSION

UNIT  2 ADMISSION  

DR  ASHA KIRAN (INTERN )

DR AMULYA (INTERN)

DR YAMINI (INTERN)

DR JAYANTH  (INTERN)

DR SURYA PRADEEP  ( INTERN)

DR VAMSHI  ( INTERN)

 DR ISMAIL (INTERN)

 DR PRADEEP  ( PG 1ST YEAR)

Dr  NIKITHA  ( PG 2ND YEAR)

DR SUFIYA  ( PG 3RD YEAR)

DR SATISH  (PG 3 RD YEAR)

55 YEARS OLD  MALE  DAILY WAGE LABOURER   CAME WITH COMPLAINTS  OF FEVER  AND COUGH ( since  20 days ) , LOOSE  STOOLS  2 DAYS  AGO  ,

PATIENT WAS APPARENTLY ASYMPTOMATIC  2O DAYS  BACK THEN HE  HAS  INSIDIOUS  ONSET  OF FEVER  , LOW GRADE  , CONTINUOUS  , NOT ASSOCIATED WITH  HEADACHE  , VOMITING,  BURNING MICTURITON  , EAR PAIN , EAR  DISCHARGE  ,FEVER IS ASSOCIATED  WITH  COUGH  AND EXPECTORATION , WHITISH  IN COLOUR  , SMALL QUANTITIY , COUGH IS CONTINUOUS  THROUGHOUT  THE DAY , NOT ASSOCIATED  WITH  WEIGHT  LOSS , NIGHT  SWEATS  ,COUGH IS ASSOCIATED WITH  CHEST  AND ABDOMINAL DISTENSION  , 1 DAY AGO PATIENT  HAD LOOSE STOOLS  5 EPISODES  / DAY  FOR 2 DAYS  , WATETRY  IN CONSISTENT  , N0T ASSOCIATED  WITH PAIN ABDOMEN  , BLOODY STOOLS, 

K/C/O  DM 2  ( 20 YEARS ON MEDICATION  ) 

NOT A K/C/O  HTN / TB  /EPILEPSY  / CVA / CAD 

PERSONAL  HISTORY  

DIET NORMAL  

APPETITE   NORMAL  

REGULAR   BOWEL AND   BLADDER   MOVEMENTS  

CHRONIC  ALCOHOLIC  TAKES  90 ML / DAY  STOPPED 3 MONTHS BACK  

ON EXAMINATION  

TEMP - AFEBRILE  

BP - 1OO/70 MMHG 

PR - 79 BPM 

SpO2 - 94 % 

GRBS  - 271 MG % 

PT IS CONCIOIOUS  , COHERENT  , COPPERATIVE ,  ORIENTED TO TIME  PLACE  AND PERSON ,  

NO SIGNS  OF  PALLOR  , ICTERUS,  CLUBBING , CYANOSIS,  GENERALIZED  LYMPHADENOPATHY  ,PEDAL EDEMA  . 

CVS  - S1 S2 HEARD 

RESP  SYSTEM  - B/L AIR  ENTRY  PERESNT , NO ADDED  SOUNDS 

CNS -  HEIGHER  MENTAL  FUNCTIONS  ARE  NORMAL  

 CRANIAL NERVES  INTACT

NECK  STIFFNESS  ABSENT 

MOTOR  SYSTEM  -  

TONE  -  B/ L UPPER  LIMBS , LOWER  LIMBS  NORMAL  .

REFLEXES  

BICEPS    ++

TRICEPS  ++

SUPINATOR  ++

KNEE ++

ANKLE  ++

CEREBELLAR  SIGNS  - ABSENT 

  

PROVISIONAL  DIGNOSIS   

FEVER  UNDER  EVALUATION  

INVESTIGATION 

CUE , FBS , PLBS ,HB A1 C ,  BLOOD CULTURE  , URINE  CULTURE  , MP STRIP TEST  , SPUTUM FOR  AFB , C/ S , GRAM STAINING  , LFT ,  RAPID DENGUE  

TREATMENT

1 INJ  PAN 40 MG IV × OD 

2 INJ  AGUMENTIN 1.2 GM × IV × TID   ( I- I -I ) 

3 TAB PCM  500mg × po× TID 

4 IVF 1 UNIT NS @ 75 ML / HOUR