general medicine
20 years old male came to OPD with a complaints of fever cough and vomitings since 5 days
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Date of admission 3/12/22
Cheif complaint
20 years old male come to OPD with a complaint of
Fever since 5 days
Vomitings since 5 days
Cough since 5 days
History of present illness
Patient was apparently asymptotic 5 days back than he developed fever high grade continuous type associated with chills and rigors relieve with medication.
Vomitins since 5 days daily 4 episodes non projectile watery in consistency
Cough since 5 days non productive
No h/o burning micturation
No h/o loose stools
No h/o head ache
History of past illness
Not k/c/o of diabetes mellitus,
Hypertension,asthma,CAD
Personal history
Occupation -student
Appetite -normal
Sleep -normal
Diet -mixed
Bowel and bladder -regular
No known drug allergies
No addictions
General examination
Patient conscious coherent cooperative well oriented to time and place
No pallor
No icterus
No cyanosis
No lymphadenopathy
No pedal edema
No malnutrition
No dehydration
Vitls
Temparature-101 F
Respiratory rate-16/min
Pulse rate-102/min
Blood pressure -110/70 mmhg
Systemic examination
Cvs
No thrills
Cardiac sounds s1s2 positive
No cardiac murmurs
Respiratory system
No dyspnoea
No wheeze
Position of trachea central
Breath sounds vesicular
Abdomen
Inspection
Shape -scaphoid
Flanks-full
Umbilicus position central
Skin no scars
No dilated veins
Palpation
Superficial palpation -no tenderness
Temparature normal
Deep palpation- liver ,spleen not palpable
No palpable mass in abdomen
Percution
No fluid thrills
Central nervous system
Level of consciousness -conscious
Speech -normal
No signs of meningeal irritations
Provisional diagnosis
Pyrexia
Clinical images
Final diagnosis
Clinical malaria
Treatment
Injection -zofer 4 mg iv
Injection -neomol 7 gm iv
Tablet -dolo 650
Tablet- Azithromycin 500 mg
Tablet -doxy 100 mg
