28year old male with fever and chills
A VISHAL
1701006001
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Chief complaints:-
Fever since 2weeks a/w chills nausea and vomiting
Hopi :-
Pt was apparently asymptomatic 1year back then he had aburn injury over left great toe formed ulcer (non healing) on routine investigations diagnosed has DM
SINCE 2 weeks pt had fever intermittent type associated with chills yellowish discoluration of urine a/w nausea and vomiting 3-4episodes , non bilious, not blood tinged,
Dry cough since 3days
Past history :-
DM since 1year
Not a known case of Htn, tb, epilepsy, CVA, CAD
EXAMINATION:-
patient was conscious, coherent, coperative
Bp:- 110/70 mm hg
Pr:- 108
Rr:-18cpm
GRBS 323
SPO2:- 100%
INVESTIGATIONS :-
PROVISIONAL DIAGNOSIS:-
PYREXIA UNDER EVALUATUON SECONDARY TO URINARY TRACT INFECTION
TREATMENT :-
1) INJ HAI 2ML/HR
2) IVF NS @100ML/HR
3) INJ 5%DEXTROSE @100ML/HR
4)INJ NEOMOL 1GM IV SOS
5) INJ PANTOP 40MG IV /OD
6) INJ ZOFER 4MG IV/BD
7) TAB DOLO 650PO/SOS
8) INJ MANGNEX FORTEX 1.5GM/IV/BD
