A 70 year old male with Fever , dribbling of urine,dry cough,myalgia

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A 70 year old male patient resident of chityal daily labour by occupation presented with chief complaints of fever since 15 days 

Dribbling of urine since 10 days

Myalgia since 5 days

Dry cough since 2 days

History of presenting illness:

Patient was apparently aymptomatic 15 days back then he had high grade  fever associated with chills ,which is intermittent for which he went to local hospital and took medicine for 7 days,no significant relief from symptoms ,so he went to hospital in Chotuppal and was diagnosed with Typhoid fever.came here for further management.

Dribbling of urine since 10 days associated with burning micturition at times not associated with dysuria ,haematuria.

History of myalgia since 5 days

History of dry cough since 2 days.

Past history:

Patient had complaints of severe low back pain, paresthesia in the lower limbs and sough for consultation and underwent L-S spine fixation 18 yrs back.

He was diagnosed with Diabetes Mellitus on regular health checkup which were conducted in the Health center; and started on Oral hypoglycemic agents since 12 yrs

History of loin pain radiating to the groin on the right side  5 yrs back; treated conservatively.

Personal History:

Non vegetarian.

Sleep was adequate.

Appetite decreased.

Bowel and bladder movements are regular

He used to smoke 12 beedis per day since he was 15 Yrs and stopped 18 yrs back.

He consumes alcohol occasionally since he was 15 Yrs.

No known allergies to drugs.

General examination:

Patient was conscious and coherent.

Pallor: Absent

icterus: Absent

Canosis , clubbing ,lymphadenopathy, bilateral pedaledema absent

Febrile, Temp : 102°F.

PR: 102 bpm; RR: 19 cpm; BP: 110/80mmHg; GRBS: 247 mg/dl.

SYSTEMIC EXAMINATION

CVS: S1, S2+; R/S: BAE+, Clear;

 P/A: Soft, Non tender, BS+,;

 CNS: HMF intact,; NFND.

INVESTIGATIONS:

Chest X Ray PA View:

  X Ray Abdomen and Pelvis ( lateral view)

X ray  Abdomen and Pelvis:

Ultrasound of Abdomen:

Colour Doppler 2D Echo:

PROVISIONAL DIAGNOSIS:

Pyrexia under evaluation

TREATMENT:

1. IVF NS/RL @75 ML/HOUR.

2. INJ. NEOMOL 100ML /IV/TID.

3. INJ. ZOFER 4MG/IV/ SOS.

4. SYP. ARYSTOZYME 15ML/PO/TID.

5. GRBS 7• PROFILE.

6. VITAL MONITORING 4TH HOURLY.

7. I/O CHARTING.