19 year old male
19 year old came with complaints of fever since 5 days
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19 year old male came with chief complaints of Fever since 3 days
Pain abdomen since 3 days
Low back ache since 3 days
Generalised weakness since 3 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 3 days back then he developed fever which is insidious in onset , gradually progressive not associated with chills and rigors
C/O pain abdomen insidious in onset , diffuse type not associated with nausea /vomiting
C/O low back ache ( insidious , gradually progressive ) not associated with tingling /numbness
C/O Generalised weakness since 3 days
PAST HISTORY:
History of fever 10 days back which was diagnosed as typhoid and was given oral medication for 3 days and iv medication for 1 day
No history of Hypertension, diabetes, asthma, epilepsy,TB
No history of prolonged hospital stay
No history of previous surgeries
Not a k/C/o DM , HTN , TB , EPILEPSY
PERSONAL HISTORY:
Appetite - decreased since 3 days
Bowel and bladder movements - Regular
Sleep - Adequate
Diet - Mixed
GENERAL PHYSICAL EXAMINATION
Patient is conscious , coherent and cooperative well oriented to time , place and person
SYSTEM EXAMINATION:
Abdominal examination-
INSPECTION
On Inspection Abdomen is flat,
no abdominal distension,
umbilicus is central and inverted ,
no scars ,sinuses
PALPATION
All inspectory findings are confirmed
Tenderness present in epigastric region and right hypochondrium region
Tenderness present in right renal angle
Blanching present on Abdomen and back
liver dullness in 5th intercoastal space,
PERCUSSION : No significant findings
AUSCULTATION: bowel sounds heard
RESPIRATORY EXAMINATION
trachea central,
normal respiratory movements,
normal vesicular breath sounds.
CARDIOVASCULAR SYSTEM
S1 ,S2 heard ,no murmurs
CNS EXAMINATION
Normal
IVF- NS/RL @100ml/hr
2.INJ PANTOP 40mg/IV/OD
3.TAB DOLO 650mg/PO/TID
4.TAB ZOFER 4mg/PO/SOS
5.INJ NEOMOL1gm IV/SOS
6.PLENTY OF ORAL FLUIDS
3/12/22
1.IVF- NS/RL @100ml/hr
2.INJ PANTOP 40mg/IV/OD
3.TAB DOLO 650mg/PO/TID
4.TAB ZOFER 4mg/PO/SOS
5.PLENTY OF ORAL FLUIDS
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