A 65 year old male with fever ,body pains and vomitings .

 A 65 year old male patient resident of miriyalguda and farmer by occupation presented with chief complaints of fever ,body pains ,vomitings since 15 days .

HOPI : The patient was apparently asymptomatic 20 days back. Then he developed fever which was insidious in onset ,high grade ,progressive and intermittent and was associated with chills and rigor ..He had vomitings as soon as he woke up in the morning which was non  projectile and billious and had food  as the content .He also gave the history of burning sensation in mouth and also complained that he had pain during swallowing .

No history of constipation 

No history of epigastric pain 

No history of increased urinary urgency and dysuria 

No hematuria 


Past History: 15 days ago he was admitted in the local hospital as he had decreased urinary output and burning micturition.He was treated with antibiotics following which the condition resolved .

No  history of Diabetes 

No history of Hypertension 

No history of epilepsy 

No history of asthma 

No history of TB

No history of Blood transfusions


Personal History: 

Diet : Mixed diet 

Appetite : Normal 

Sleep : Adequate 

Bowel and Bladder: Regular 

Addictions : He is a chronic alcoholic since 30 years ,and he consumes 2-3 units of whisky on a daily basis 

Family history : No significant family history 


General Examination: 

Examination was done after taking the consent from.the patient and in a well ventilated room .

Patient was conscious and coherent 

Moderately built and nourished 

Well oriented to place time and person 


No Pallor 

No icterus 

No cyanosis 

No clubbing of fingers 

No lymphadenopathy 

No pedal edema 


Vitals : 

Temperature: Febrile 

Pulse : 84 bpm with normal volume and rhythm 

BP : 110/70 mmhg

Respiratory Rate: 16 cpm 


Systemic examination 

Respiratory System 

Inspection: 

Chest appears symmetrical 

Trachea is in central position 

No dilated veins or scar marks present 


Palpation : 

Trachea is in central position 

Vocal fremitus present 

Auscultation: NVBS in all areas 


CVS : S1 S2 heard without murmurs 

Abdominal Examination: 

Inspection : 

Abdomen appears obese 

No dilated veins or scar marks 

 Palpation: 

Soft ans tenderness present in the left flank area on Palpation 

Liver is palpable 

No other palpable mass 

Auscultation : 

Bowel sounds heard 








Investigations: 









 



Provisional diagnosis : Left pyelonephrits 

Treatment: 

- 

Inj neomol  1gm IV/SOS

Inj piptaz 4.5gm iv TID

Tab Pan 40mg po/od

Tab Pcm 650mg PO/TID 

Betadine gargles BD

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