35yr OLD MALE WITH VIRAL PYREXIA with Recurrent UTI

Pr came with complaints of 

fever since 2 days , cold& cough since 2 days

- C/O Left ear pain and associated with cold since 1 month.

- C/O loin pain left side (pricking type)

HOPI :

Pr was apparently asymptotic 2 days back , then he developed fever , which is sudden in onset & associated with chills and rigors

Not relieved on medication.

- dry cough since 2 days.

- no c/o chest pain , palpitations , syncopal attack.

- no c/o orthoptera , PND

- no c/o pedal edema decreased urine output.

PAST HISTORY :

H/O  Renal calculi surgery 1 1/2 yr back.

- not a k/c/o DM , HTN , Asthma , Epilepsy,TB ,CVA ,CAD.

ON EXAMINATION :

Pt is C/C/C

Temp :

BP :110/70 mmhg

PR : 90 bpm

RR : 22 cpm

GRBS : 200 mg/ dl

General examination :

No pallor , icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema.

SYSTEMIC EXAMINATION 

CARDIOVASCULAR SYSTEM:

Inspection:

Chest wall is bilaterally symmetrical.

No precordial bulge

No visible pulsations, engorged veins, scars, sinuses

Palpation:

JVP: normal

Apex beat: felt in the left 5th intercostal space in the mid clavicular line.

Auscutation:

S1, S2 heard , No murmurs

RESPIRATORY SYSTEM-

Position of trachea: central

Bilateral air entry +

Normal vesicular breath sounds - heard

No added sounds.

PER ABDOMEN:

Abdomen - Tenderness + at umbelical region

No organomegaly.

Bowel sounds heard.

No palpable mass or free fluid 

CENTRAL NERVOUS SYSTEM:

Patient is Conscious 

Speech: normal

No signs of Meningeal irritation

Motor & sensory system: normal

Reflexes: present

Cranial nerves: intact

DIAGNOSIS : Viral pyrexia with Recurrent UTI

Soap notes Day 1
Unit 6
Ward case  35 yr male
S : nose block ( left nostril) reduced
     C/o ringing sensation in the ear
      1 episode of vomiting yesterday night
        Fever spike yesterday night
O :
Pt is C/c/c
Temp :102.5 F
BP:110/70 mmHg
PR :82 BPM
CVS :S1S2 +
RES - NVBS, no crepitations
PA : Tenderness + at RT illiac fossa
A : viral pyrexia with Recurrent UTI
P :
1. T. PCM 650 mg/ PO/TID
2. T.MVT / PO/ OD
3. T. ULTRACET /PO/SOS
4. Syp. ASCORIL D/ PO/OD
5. Plenty of water
6. Fever charting
7. T. LEVOCETRIZINE 5 mg/ PO/ OD
8. Inj NEOMOL 1 GM / IV infusion
9. Monitoring vitals BP,PR, RR