65yr old male with? Military TB
A65yr old male farmer by occupation came with the complaints of
Fever on & off since 20 days
Body pains since 20 days
Cough (dry) since 4 days
HOPI
Patient was apparently asymptomatic 20 days back had fever with evening rise of temperature
There is loss of appetite &loss of weight
Fever is associated with dry cough
Fever is associated with body pains
No h/o sorethroat
No h/o burning micturition
Past history
N/K/C/O DM,HTN, EPILEPSY,ASTHMA, HYPOTHYROIDISM
No h/o previous TB
PERSONAL HISTORY
DIET - Mixed
Appetite - Normal
Sleep-adequate
Addictions -
Chronic smoker since 20 years
1/2 pack per day
General examination
Patient is c/c/c
Oriented to time ,place , person
No pallor, icterus , cyanosis, clubbing, koilonychia , lymphadenopathy,edema
Vitals
BP- 110/80 mmHg
PR-72 Bpm
RR -16cpm
Temp-99.6F
Systemic examination
CVS - S1S2+,NO Murmurs
RS -BAE+,NVBS HEARD
P/A-SOFT ,NON TENDER,NO ORGANOMEGALY
CNS - NAD
FEVER CHART
HEMOGRAM
PLBS
RBS
VIRAL PYREXIA
DENOVO DETECTION DM
TREATMENT
1) IVF NS @100ML/HR
2) TEMPERATURE MONITOR ONE HOURLY
3) GRBS MONITORING 6TH HOURLY
4) STRICT I/o CHARTING
SOAP NOTES DAY 1
17/05/2022
S:
C/o Headache &cough
O:
PATIENT IS C/C/C
No pallor, clubbing, icterus, cyanosis, koilonychia, lymphadenopathy,edema
VITALS :
BP - 110/80 MMHG
PR- 84 BPM
SPO2 - 98%
TEMP - 99.6°F
CVS - S1 S2 +
RS - BAE +
CNS - NAD
P/A - SOFT , No TENDERNESS,
NO GUARDING
NO RIGIDITY
A:
VIRAL PYREXIA
DENOVO DETECTED DM
P:
1)IVF NS @100 ML /HR
2) STRICT TEMPERATURE MONITORING ONE HOURLY
3) GRBS MONITORING 6TH HOURLY
4) STRICT I/O CHARTING
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