52 year old male with fever

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CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever  

This is a case of  52 year old male suffering from fever and pedal edema

CHIEF COMPLAINTS:

Complaints of Fever  since 2 days

Slurred speech for half an hour 2 days back then he regained his consciousness

B/L Pedal Edema since 2 days 

Decreased appetite since 2 days 

Abdominal distension

Decreased Urine output since 1 day 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 30 days back then he developed B/L Pedal Edema pitting type for which he used herbal medicine and his edema got resolved.

10 days back he again developed B/L Pedal Edema pitting type associated with abdominal distension and decreased Urine output for which he was treated conservatively

Since 2 days he had complaints of Fever,low grade, intermittent a/w pitting type of pedal edema, abdominal distension and decreased Urine output.

HISTORY OF PAST ILLNESS:

H/O seizures 

one episode in childhood

one episode 30 yrs back 

one episode 10 yrs back

Not a k/c/o HTM,DM,TB ,ASTHMA, THYROID DISORDERS.

PERSONAL HISTORY:

Appetite: decreased

Diet: mixed 

sleep: adequate

Bowel and bladder: Regular

addictions:H/o BD Smoking since 18 years (4-5 BD's per day)

FAMILY HISTORY: 

Insignificant.

GENERAL EXAMINATION: 

Patient is concious, coherent and oriented to time,place and person.

VITALS:

Pulse rate: 92 BPM 

Respiratory rate: 22CPM 

BP: 110/90.

spO2: 98% at room air 

SYSTEMIC EXAMINATION:

CVS: S1 and S2 - present 

CNS: NAD 

LUNGS : B/L air entry present 

INVESTIGATIONS:

TREATMENT:

1-Inj . Lasix 40mg I.V  BD 

2-I.V fluids 10 NS 1amp optineuron 

I.V Fluids 10 RL @75ml/hr 

3- Inj Thiamine 100mg in 100ml NS IV Bd 

4- INJ Neomol 2gm I.V 

5- Protein powder 2 scoops in 100ml milk TID 

6- Tab dolo 650 mg PO SOS.