GENERAL MEDICINE CASE

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December 19,2021

65 YEAR OLD MALE WITH FEVER UNDER EVALUATION.

65 year old male came to casualty with chief complaints of high grade fever with chills since 10 days.

History of present illness:

Patient was apparently asymptomatic 10 days back   then he developed high grade fever with chills and  backache.

Patient also had  3-4 episodes of vomitings since 5 days.

He also   complaints of swellings  of legs 2 day prior to the onset of fever which subsided without any treatment.

No complaints SOB,cough,burning micturition, and loose stools.

Patient's daily routine:-

Patient is a farmer by occupation.He usually wakes up at 6' O clock in the morning then goes for a walk for 1 hr & then returns home completes his brushing & bathing  & finishes his breakfast and goes to the field by around 9:30 in the morning and returns home by 6 pm in the evening ,relaxes for 1 hour & takes his dinner around by 8:30- 9 pm and goes to bed by 9:30- 10 pm.

After the attack of backache & fever he stopped going to the field .

Past history:-

Patient was diagnosed with DM 5 years ago started on OHA.

Currently patient is on INJ .MIXTARD  10 U in the morning & 8 U at night

4 years ago patient came to our hospital with c/o SOB and was told to have lung infection and ?mass and was started on insulin.

Since 4 years patient had skin lesions with scaling over legs and hands which progressed gradually,for which he used steroids and tapered.As the lesions kept progressing patient underwent skin biopsy 1month ago in outside hospital which showed munromicroabscess suggestive of psoriasis. He has been using medication for psoriasis since 1 month.

H/O unstable angina 1 and half year back-PTCA was done.

Not a K/C/O HTN,TB,asthma,epilepsy, thyroid disorders.

Personal history:

Diet-mixed

Appetite-normal

sleep-adequate

Bowel and bladder movements-regular

Family history:

Not significant

General examination:

Patient is conscious, coherent, cooperative.

No pallor,icterus,cyanosis,clubbing,lymphadenopathy,edema.

Vitals on admission:

Temperature-99 F

PR-64 bpm

RR-18 cpm

BP-80/60 mmHg

Systemic examination:

CVS-S1,S2 heard,No murmurs

CNS-No FND

P/A-soft,non tender

Clinical images:

Psoriatic plaques on B/L upper and lower lims:

Investigations:

Provisional dignosis:

Fever under evaluation with myalgias under evaluation with low backache 2°to radiculopathy.

With H/O PTCA 1 and half year back

With K/C/O DM-type 2

Treatment:

IVF NS @150 ml/hr-bolus given

             @75 ml/hr- maintenance 

TAB.DOLO 650MG TID

INJ.NEOMOL 1G IV SOS

Temperature charting 4th hrly

INJ.AVIL 2CC SOS(IF CHILLS +)

GRBS monitoring 6th hrly

INJ.HUMAN ACTRAPID ACCORDING TO GRBS

TAB.ECOSPIRIN 75/20 MG PO OD

INJ.PIPTAZ 4G IV QID