50 year old male with abdominal pain and fever

 


Note: This is an online E Log book recorded by Manish to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.


Chief complaints: Fever with chills and headache since 4 days, abdominal pain since 4days


HOP1: 50 yr old male patient farmer  by occupation brought to casualilty with fever, abdominal pain(right hypochondrium), shortness of breath . He had high grade, continuous fever  associated with chills and headache. His pain in the abdomen aggregated on intake of food.Burning micturition since 4 days. He also noticed decreased urine output. Abdominal distension since 4days and shortness of breath on exertion since 4 days.


Past illness: - 


Personal History: Mixed diet

Black stools 

 Sleep Adequate 

Chronic alcoholic 



Family History: Non significant 


Negative History : No History of ,Hypertension,diabetes,Vomiting ,Palpitations and asthma 


General Examination: 

Patient is Conscious, 

Moderately Built and Nourished.

Pallor Absent

Icterus Absent

Clubbing Absent

Cyanosis Absent

Lymphadenopathy Absent

Edema Absent 


Vitals : 

Temperature - 98.6 degree f

Pulse  90/min

B.P 110/90mmHg

SpO2:98%



Lab diagnosis: 







Treatment: 


Inj MAGNEX FORT 1.5gm/IV/BD


Inj. PAN 40mg /IV/OD


Inj OPTINEURON 1amp in 100NNS IV/over 30mIn


Tab . DOLO 65g PO/QID


Inj METROGYL 150ml 750 mg IV/TID

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