60 yr old female
A 60 yr old female patient came to the opd on 30 June with chief complaints of fever since 5days with associated chills and rigors along with loss of appetite .
History of present illness :
Pt was apparently asymptomatic 5days ago then she developed fever which was gradual in onset along with chills and rigors all over the body and loss of appetite since 4 days
No history of burning micturation nausea or vomiting
Past history :
She is a known case of hypertension since 1 month
No similar complaints in the past .
General examination
Patient is conscious coherent and cooperative
Bp : 90/60
Resp rate :16 cycles /min
Pulse rate : 70 beats /min .
Temp : afebrile
No pallor ,icterus , clubbing ,cyanosis , lymphadenopathy,edema
On systemic examination :
Cvs : S1,S2 heard
On resp examination : vesicular breath sounds heard
On CNS examination : all reflexes are intact .
Investigations
Plan of management :
1.IV fluids 100ml/hr
2.tab PCM 650mg orally. TID
3.INJ .Neomol 1gm SOS (temp >102°F)
4.Inj.Optineuron 1amp in 100ml Ns Iv OD
5.bp/pulse rate/spo2 monitoring
6.temp charting
7.Inj pan IV/OD
