A 77 year old male with fever,cough and abdominal discomfort since 3 days

 

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CASE:

A 78 year old male came with chief complaints of

-Fever since 6 days

-Abdominal discomfort since 3 days

-Cough since 3 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 6 days ago. Then he developed fever (mild to moderate grade) which was insidious in onset,gradually progressive in nature associated with chills.

4 days ago,

He had an episode of seizures where all of his limbs were stiff,up rolling of eyes and frothing from the mouth was present,he passed urine during the seizure episode.He regained consciousness after half an hour of taking him to the local hospital.

3 days ago,

He developed cough with sputum which was whitish and non blood stained. 

He complaints of bloating of abdomen associated with belching.

DAILY ROUTINE:

He wakes up by 7 AM in the morning, does his morning routine and has his breakfast by 9 AM and off he goes to work by 10 AM (He’s a daily wage labourer). He usually has rice and chicken.

He has his lunch by 1 PM. He usually has rice and chicken.

At 4 PM, he has tea with biscuits. 

Winds up his work by 4 PM and returns home.

He has his dinner by 6 PM. 

He goes to bed by 8-9 PM in the night.

PAST HISTORY:

Patient is a known case of DM since 1 year and he is on medication.

History of cholecystectomy 3 years ago.

He is not a known case of HTN,asthma,epilepsy,tuberculosis and thyroid abnormalities.

PERSONAL HISTORY:

Sleep: adequate 

Apetite: decreased

Diet: mixed

Bowel and bladder movements: 

Addictions: none 

FAMILY HISTORY:

no similar complaints in the family

GENERAL EXAMINATION:

Patient is conscious,coherent and cooperative, moderately built and moderately nourished.

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy: absent

Pedal edema: absent

VITALS:

Temperature: 100 degree farenheit

Pulse: 82 beats/minute

Blood pressure:110/70mm Hg

Respiratory rate: 18 cpm

SYSTEMIC EXAMINATION:

CVS: S1 and S2 are heard

RS: bilateral air entry present, right infraclavicular wheeze is present and right infeascapular crepts are present.

CNS: E4V5M6, higher mental functions intact

Abdomen: soft and non tender, bowel sounds are present

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

Pyrexia under evaluation of bicytopenia?

With Seizure under evaluation??

TREATMENT:

Inj. Monocef 1gm iv BD

Tab doxycycline 100mg PO BD

IV fluids NS at 50ml/hr

Inj. Pantop 40mg iv BD

Inj. zofer 4mg iv BD

Inj. HumanActrapidinsulin sc. TID

Inj. Levipil 500mg iv BD

T. Dolo 650 mg PO BD

Inj. Neomol 1mg iv if temperature is more than 100F