Case history -9
25 October , 2021
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A 24 yrs old male patient presented to the opd with chief complaints of fever, body pains, yellow discolouration of eyes.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 6 months back then developed yellow discolouration of eyes for which he took herbal medication and condition was relieved.
Post ugadi patient developed fever , and had low red blood cell count for which iron injections were given
On 21/10/21 patient presented to the opd with chief complaints of
Fever since 10 days
Cough since 10 days
Body pains since 10 days
Difficulty in passing stools since 2 days.
PAST HISTORY:
Patient has no history of surgeries in the past
No history of diabetes, CAD , epilepsy , tuberculosis.
FAMILY HISTORY:
No history of any surgeries in the family.
PERSONAL HISTORY:
Diet - mixed
Sleep- adequate
Bladder movement- regular
Appetite - normal
No habit of smoking
No habit of consuming alcohol
GENERAL EXAMINATION:
Patient is conscious , coherent and cooperative.
No cyanosis
No lymphadenopathy
Pallor is seen
Icterus is seen
VITALS:
Temperature: 36.1 degrees celsius
Pulse rate: 92 beats /min
BP: 100/60 mm of Hg
Respiratory rate: 16/min
SYSTEMIC EXAMINATION:
CVS:
No thrills
S1S2 heard
RESPIRATORY SYSTEM:
Position of trachea- Central
Breath sounds- vesicular
No wheeze
No dyspnea
ABDOMEN:
Shape of abdomen- Scaphoid
No tenderness
No palpable mass
No bruits
CNS:
Level of consciousness - alert
Speech - normal
No neck stiffness
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
Viral pyrexia with anemia
TREATMENT:
1. Inj.Neomol
2. Tab dolo 650mg
3. Tab. Orofer XT
4. Syp.Ascoril
5. Syp.Cremaffin
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