VIRAL PYREXIA UNDER EVALUATION

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A 50 year old male came to opd with complaints of high grade fever since 3 days associated with chills

Cold since 3 days

Cough since 3 days,productive, mucoid,not associated with shortness of breath

No h/o chest pain, palpitations

No h/o pedal edema, decreased urine output, abdominal distension

No h/o HTN,DM,TB, Asthma, epilepsy

Personal history:

Appetite-normal

Diet-mixed

Bowel and bladder movements- regular

No known allergies

He's a known smoker,he smokes 5-6 cigarettes a day n stopped smoking since a week

GENERAL EXAMINATION:

Patient was examined in a well lit room after taking consent.

Patient is conscious, coherent and cooperative.

Pallor - absent 

icterus - absent

Cyanosis - absent

Clubbing - absent

No lymphadenopathy 

No pedal edema.

Vitals:

Temperature: 98.2F

BP :130/90 mmHg

PR : 98bpm

RR: 22 cpm

SpO2 98% in room air

SYSTEMIC EXAMINATION:

CVS: S1 S2 heard

no thrills and murmurs

RS : trachea central

 BAE- present 

Normal vesicular Breath sounds

CNS: No focal neurological deficits

P/A : soft , non tender

Umbilicus - inverted

All quadrants moving equally with respiration

Scars- No scars seen

No palpable spleen and liver

Normal bowel sounds heard.

INVESTIGATIONS:

CBP:

HB:12.8 gm/dl

Total count:5000 cells/cumm

Platelet count:2.07 lakh/cumm

CUE:

Albumin-trace

Pus cells-4

Sugar-nil

Epithelial cells-2-3

LFT:

T.Bilirubin-0.53

D.bilirubin-0.20

SGOT-69

SGPT-78

Alkaline phosphatase-177

T.proteins-6.6

Albumin-3.2

A/g-0.95

RFT:

S.creatinine-0.8

S.urea-12

S.electrolytes:

Sodium-139

Potassium-3.7

Chloride-98

Rapid HBSg: negative

HIV 1 and 2: negative

HCV: Negative

ECG:

TREATMENT:

1)IVF NS,RL @100 Ml/hr

2)Inj.pan 40mg /iv/od

3)INJ.optineuron 1 amp in 100 ml NS/iv/od

4)Tab.Dolo 650 mg po/sos

5) temperature monitoring 4th hourly monitoring

6)strict bp,pr monitoring 4th hourly