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




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