65 F WITH COUGH, FEVER, HEADACHE

 C/O HEADACHE SINCE 3 DAYS

C/O FEVER, COUGH SINCE 1 DAY

HOPI

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS BACK THEN DEVELOPED HEAD ACHE -INSIDIOUS ONSET ,DIFFUSE  ,GRADUALLY PROGRESSIVE RELIEVING WITH MEDICATION

H/O FEVER LOW GRADE ON AND OFF RELIEVED WITH MEDICATION

H/O PHOTOPHOBIA

H/O WATERING FROM EYES

NOT ASSOCIATED WITH VOMITING , NAUSEA

PAST HISTORY

NO HISTORY OF DM, HTN,ASTHMA,EPILEPSY,CAD,CVA

PERSONAL HISTORY:

DIET:MIXED

SLEEP:ADEQUATE

BOWEL AND BLADDER:REGULAR

ADDICTIONS:NO

APPETITE:NORMAL

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON.

NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA.

VITALS:

TEMPERATURE:98.6

BP:110/70 MM HG

PR:80 BPM

RR:18 CPM

SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD NO MURMURS.

RS:BAE +,NO MURMURS

PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY

CNS:NO FOCAL NEUROLOGICAL DEFICITS.

INVESTIGATIONS:

Value  Range	Name  Value  Range
COMPLETE URINE EXAMINATION (CUE)   09-01-2024 04:44:PM  COLOUR Pale yellow    APPEARANCE Clear    REACTION Acidic    SP.GRAVITY 1.010    ALBUMIN trace    SUGAR Nil    BILE SALTS Nil    BILE PIGMENTS Nil    PUS CELLS 3-4    EPITHELIAL CELLS 2-3    RED BLOOD CELLS Nil    CRYSTALS Nil    CASTS Nil    AMORPHOUS DEPOSITS Absent    OTHERS Nil	HBsAg-RAPID   09-01-2024 04:44:PM Negative
Anti HCV Antibodies - RAPID   09-01-2024 04:44:PM Non Reactive	POST LUNCH BLOOD SUGAR   09-01-2024 04:44:PM 188 mg/dl 140-0 mg/dl
RFT   09-01-2024 04:44:PM  UREA 11 mg/dl 50-17 mg/dl  CREATININE 0.8 mg/dl 1.2-0.6 mg/dl  URIC ACID 3.9 mg/dl 6-2.6 mg/dl  CALCIUM 10.0 mg/dl 10.2-8.6 mg/dl  PHOSPHOROUS 5.5 mg/dl 4.5-2.5 mg/dl  SODIUM 140 mEq/L 145-136 mEq/L  POTASSIUM 3.1 mEq/L 5.1-3.5 mEq/L  CHLORIDE 99 mEq/L 98-107 mEq/L	LIVER FUNCTION TEST (LFT)   09-01-2024 04:44:PM  Total Bilurubin 0.54 mg/dl 1-0 mg/dl  Direct Bilurubin 0.17 mg/dl 0.2-0.0 mg/dl  SGOT(AST) 28 IU/L 31-0 IU/L  SGPT(ALT) 25 IU/L 34-0 IU/L  ALKALINE PHOSPHATE 222 IU/L 141-53 IU/L  TOTAL PROTEINS 6.2 gm/dl 8.3-6.4 gm/dl  ALBUMIN 2.85 gm/dl 4.6-3.2 gm/dl  A/G RATIO 0.85
RFT   11-01-2024 06:33:AM  UREA 20 mg/dl 50-17 mg/dl  CREATININE 0.8 mg/dl 1.2-0.6 mg/dl  URIC ACID 4.3 mg/dl 6-2.6 mg/dl  CALCIUM 9.6 mg/dl 10.2-8.6 mg/dl  PHOSPHOROUS 4.0 mg/dl 4.5-2.5 mg/dl  SODIUM 137 mEq/L 145-136 mEq/L  POTASSIUM 3.3 mEq/L 5.1-3.5 mEq/L  CHLORIDE 104 mEq/L 98-107 mEq/L	LIVER FUNCTION TEST (LFT)   11-01-2024 06:33:AM  Total Bilurubin 1.07 mg/dl 1-0 mg/dl  Direct Bilurubin 0.19 mg/dl 0.2-0.0 mg/dl  SGOT(AST) 20 IU/L 31-0 IU/L  SGPT(ALT) 16 IU/L 34-0 IU/L  ALKALINE PHOSPHATE 222 IU/L 141-53 IU/L  TOTAL PROTEINS 7.4 gm/dl 8.3-6.4 gm/dl  ALBUMIN 4.0 gm/dl 4.6-3.2 gm/dl  A/G RATIO 1.17

HEMOGRAM

HB 10.2GM/DL

TC 9300CELLS/CUMM

N/L/E/M/B 57/31/06/06/00

PCV 31.2

MCV 78.2

RBC 3.09 MILLION /CUMM

PLATELET COUNT 3.41LAKHS/CUMM

TREATMENT

TAB AUGUMENTIN 625 MG BD

TAB DOLO 650 MG BD

TAB LEVOCET 10MG PO H/S

TAB PAN 40MG  OD

SYP GRILLINCTUS 10ML TID

SYP POTCHLOR 10ML TID