75 year old Male with Fever and Cough since 4 Days.

Chief Complaints
75 year old came to the casualty with c/o 
fever, cold, cough since 4 days.
HOPI
Fever is intermittent in nature, associated with chills .
Fever is relieved by taking medication.
Cough is associated with Sputum.
Colour whitish In colour.
Watery in consistency.
Volume :10 ml
Past History

Patient was apparently asymptomatic till 2003 , then patient had B/L knee pain which gradually aggravated, then patient was started on NSAID'S daily for 3 years.

Then in 2006- one day pt had continuous episodes of loose stools, 6-7 episodes per day with Anuria. 
So Patient visited a local Hospital and underwent 1 session of hemodialysis.

2 YEARS BACK : pt experienced Polyuria , polydypsia for 2 days for which he visited nearby RMP and was diagnosed as DIABETIC and started on OHA.

At present since 10 DAYS , patient had decrease of appetite, generalised weakness> took OHA and didn't take any food. Then Patient experienced 1 episode of hypoglycemia GRBS: 18 mg/dl ( frothing and uprolling of eyes). Then his attender gave him sugar water in ambulance- Recovered.
Had similar episode 2 days back.
decrease in Appetite since 10 days.

k/c/o Diabetes since 10 years
Persona lHistory
Addictions: Chronic smoker ( chutta) 5-6/day for 30 years




O/E
General Examination.
Temp: 96.9 F
PR: 68 bpm.
BP: 120/90 mm hg.
Spo2 : 98% @ RA.

CVS:
 S1 S 2 heard
Respiratory System :
 Fine crepts on right side
P/A : soft, non tender
Decreased chest movements on right upper chest.
Percussion : Dull note in Infraclavicular Region on Right Side.
PROVISIONAL DIAGNOSIS: Pyrexia under Evaluation with DM type 2. ? Pneumonia

TREATMENT given:
- IVF NS @ 20 ml/kg/hr IV stat.
Ns @ 10ml/kg/hr continuous.
-Inj. PANT OP 40MG IV/OD.
-INJ.ZOFER 4 mg IV/SOS
- INJ.NEOMOL 1gm IV/SOS ( temp > 101 F)
- Inj. HAI S/C according to sliding scale.
- Nebulisation with BUDECORT 12th hrly.
- Grbs 6 th hrly.
- vitals monitoring 4 th hrly.

Investigations






Hemogram on 24/9/21



Right lung



Nephro referral
Cyanosis absent


 SOAP NOTES
A 75 yr old male with Pyrexia under evaluation.
Subjective- 2 episodes of loose stools, fever with chills.

Objective
Temp: 99.1 F
BP: 110/50 mmhg
PR: 90 bpm
Cvs: S1 S 2 +
Respiratory Sounds:  
Fine Crepts in Infraclavicular area.
P/A : soft, non tender
CNS: NAD.

Assessment
Pyrexia under evaluation with type 2 DM,
NSAID induced Nephropathy.


Treatment
IVF NS RL@ 150 ml/hr.
Inj. Pant op 40 mg IV/ OD.
Inj.Zofer 4mg IV/ SOS.
Inj. Neomol 1g IV/ SOS.
Inj.HAI s/c according to sliding scale.
Inj.DERIPHYLLIN 2 cc IV/ BD.
Nebulisation with Budecort 6th hrly, Duolin - 8 th hrly.
T.PREGABALIN 75 mg OD(9pm).
T.Azitromycin 500 mg PO/ OD.
Grbs 6th hrly.
Vitals monitoring 4 th hrly.

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