A 67yr old male with body pains and fever
Oct 10,2022
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Patha Sindhusha
A 67 yr old male patient came to the causality with chief complaints of
- fever since 10 days
- body pains and generalized weakness since 10 days
- shortness of breath since 5 days
- abdominal pain since 2 days
History of presenting illness
Patient was apparantly asymptomatic 10 days back later he developed fever associated with chills with evening of rise of temperature .
H/o burning mi
H/o dry cough , generalized weakness and body pains .
H/o of an episode of vomiting on 4th day of illness had food particles as content which was no bilious and non projectile.
H/o breathlessness in exertion since 5 days
H/o epigastric pain which is of squeezing type
H/o abdominal pain since 2 days
PAST HISTORY :
-In 2007; he underwent Surgery for Aortic dissection.
-And after 10 months Underwent ESWL for kidney stones in Right Kidney.
-H/O Hypertension since 15 years.
-No H/O Diabetes;Asthma;Tuberculosis;Epilepsy.
PERSONAL HISTORY :
-He wakes up at 5:00 am and
-Does his work as milk vendor ;
-Eat's meal for 3 times a day and had good appetite and
-Has adequate sleep and
-Bowel - regular
-H/O burning micturition since 10 days.
-No addictions.
FAMILY HISTORY:
No similar complaints in any one of his family members.
GENERAL EXAMINATION:
Patient is Conscious; Coherent and Cooperative and Well oriented to time;place and person.
Pallor - Absent
Icterus - Present
Clubbing - Absent
Kolinychia -Absent
Generalised Lymphadenopathy -Absent
Bilateral Pedal Edema -Absent
VITALS :
Pulse Rate - 102 bpm
Blood pressure - 90/60 mm of Hg
Respiratory Rate - 26cpm
SpO2 - 97%
GRBS - 150mg/dl
SYSTEMIC EXAMINATION:
Respiratory system;
-Shape of the chest normal,
-Trachea appears to be in centre
-6 to 8 inch longitudinal Scar is present over the sternum.
-Normal vesicular breath sounds heard
Cardiovascular system;
- S1 S2 heard
- No thrills and murmurs
Abdomen ;
- Shape of the abdomen
- tenderness present in epigastric region
- no palpable masses
- hernial orifices normal
- liver and spleen are not palpable
CNS ;
- pateint is conscious
- speech normal
INVESTIGATION
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