65 yr old male with fever,dry cough and generalised weakness
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CASE PRESENTATION:
A 65 year old male came to casualty with c/o
Fever since 20 days
Cough since 10 days
Generalised weakness since 10 days
HOPI:
Patient was apparently asymptomatic 20 days back then he developed fever which is of high grade,intermittent, associated with chills and no diurnal variation.
He had Cough since 10 days which is associated with sputum which is white in colour
He also had loss of appetite and generalised weakness
No h/o nausea, vomiting
No h/o loose stools
No h/o constipation
PAST HISTORY:
K/C/O TB 1 year back(used medication for 6 months)
Not a K/C/O DM/HTN
TREATMENT:
1.INJ.AUGMENTIN 1.2 GM/IV/BD
2.IV FLUIDS NS@ UO + 30 ML/HR
3.INJ.NEOMOL 1GM/IV/SOS(if temp>101 F)
4.T.AZITHROMYCIN 500MG PO/OD
5.INJ.PAN 40 MG/IV/OD
6.INJ.ZOFER 4MG/IV/SOS
7.NEB.WITH DUOLIN ,BUDECORT 6 TH HOURLY
8.SYP.BENADRYL 10 ML/PO/TID
9.T.DOLO 650 MG/PO/TID
10.VITALS MONITORING
ICU BED 3
Day 1(22/10/22)
S:
Fever spikes +
Cough
O:
1.INJ.AUGMENTIN 1.2 GM/IV/BD
2.IV FLUIDS NS@ UO + 30 ML/HR
3.INJ.NEOMOL 1GM/IV/SOS(if temp>101 F)
4.T.AZITHROMYCIN 500MG PO/OD
5.INJ.PAN 40 MG/IV/OD
6.INJ.ZOFER 4MG/IV/SOS
7.NEB.WITH DUOLIN ,BUDECORT 6 TH HOURLY
8.SYP.BENADRYL 10 ML/PO/TID
9.T.DOLO 650 MG/PO/TID
10.SYP.CREMAFFIN 10 ML/PO/HS
11.VITALS MONITORING
AMC BED 6
Day 2(23/10/22)
S:
Fever spikes + (1 spike)
O:
1.INJ.AUGMENTIN 1.2 GM/IV/BD
2.IV FLUIDS NS@ 50 ML/HR
3.INJ.NEOMOL 1GM/IV/SOS(if temp>101 F)
4.T.AZITHROMYCIN 500MG PO/OD
5.SYP.BENADRYL 10 ML/PO/TID
6.SYP.CREMAFFIN 15 ML/PO/SOS
7.TAB.PCM 650 MG PO/BD
8.VITALS MONITORING
AMC BED 2
Day 3(24/10/22)
S:
Fever spikes + (1 spike)
O:
1.INJ.AUGMENTIN 1.2 GM/IV/BD
2.IV FLUIDS NS@ 50 ML/HR
3.INJ.NEOMOL 1GM/IV/SOS(if temp>101 F)
4.T.AZITHROMYCIN 500MG PO/OD
5.SYP.BENADRYL 10 ML/PO/TID
6.SYP.CREMAFFIN 15 ML/PO/SOS
7.TAB.PCM 650 MG PO/BD
8.SPOROLAC DS
9.VITALS MONITORING
MEDICAL WARD
Day 4(25/10/22)
S:
Loose stools(1 episode)
Cough
Decreased appetite
O:
1.INJ.AUGMENTIN 1.2 GM/IV/BD
2.IV FLUIDS NS@ 50 ML/HR
3.INJ.NEOMOL 1GM/IV/SOS(if temp>101 F)
4.T.AZITHROMYCIN 500MG PO/OD
5.SYP.BENADRYL 10 ML/PO/TID
6.SYP.CREMAFFIN 15 ML/PO/SOS
7.TAB.PCM 650 MG PO/BD
8.TAB.NODOSIS 500MG/PO/OD
9.TAB.SNELLAL 550 MG/PO/OD
10.NEB.DUOLIN BUDECORT
11.VITALS MONITORING
MEDICAL WARD
Day 5(26/10/22)
Cough
Fever spikes+
O:
1.INJ.AUGMENTIN 1.2 GM/IV/BD
2.TAB.ULTRACET PO/BD
3.INJ.NEOMOL 1GM/IV/SOS(if temp>101 F)
4.T.AZITHROMYCIN 500MG PO/OD
5.SYP.BENADRYL 10 ML/PO/TID
6.SYP.CREMAFFIN 15 ML/PO/SOS
7.TAB.PCM 650 MG PO/BD
8.TAB.NODOSIS 500MG/PO/OD
9.TAB.SNELLAL 550 MG/PO/OD
10.NEB.DUOLIN BUDECORT
11.VITALS MONITORING
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