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Date of admission:- September 23 2021
A 50 yr old male patient farmer by occupation presented to the opd with chief complaints of fever , cough , loose stools since 1 month
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 20 days back then he developed fever which is low grade intermittent type and associated with chills and rigor since 1 month and not associated with headache ,nausea and vomiting
Initially patient had dry cough since 10 days then he had continuous wet cough (with sputum) since 20 days loose stools watery in consistency green to yellow in colour, multiple epidoses immediately after food /fluid intake , high volume not associated with abdominal pain and vomiting
Patient also complaints of loss of appetite and reduced sleep since 20 days and weight loss more than 20 kgs
HISTORY OF PAST ILLNESS
There is no history of hypertension, diabetes mellitus , tuberculosis, asthma, and epilepsy
There is no history of surgery
PERSONAL HISTORY
Diet is mixed
Sleep is reduced
Bowel - loose stools
Loss of appetite
There is no history of allergies to known drugs
Patient is non alcoholic and non smoker
He is married and has 2 children
FAMILY HISTORY
There is no history of similar complaints in the family members
GENERAL EXAMINATION
The patient is conscious, coherant and uncooperative. He is well oriented to time , place and person . Moderately built and nourished
No anemia
No Pallor
No icterus
No cyanosis
No clubbing
No generalized lymphadenopathy
VITALS
Vitals
PR :-82bpm
RR :-20cpm
BP :-100/70mmHg
SpO2 :-98% in room air
GRBS :-105mg/dl
Temperature febrile
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 midclavicular line
Ausculation:
S1 ,S2 Heard
RESPIRATORY SYSTEM
Bilateral airway +
Position of trachea- central
Normal vesicular breath sounds - heard
No added sounds
PER ABDOMEN
Abdomen is soft and non tender
Bowel sounds heard
Free fluid grade 1 ascites
CENTRAL NERVOUS SYSTEM
Patient is conscious
Reflexes are normal
Speech is normal
INVESTIGATION
ECG :-
Tounge associated with oral candidiasis
DIAGNOSIS:-
HIV POSITIVE
TREATMENT:-
IVF- normal saline 75 ml/hr;Ringer lactate 75ml/hr
Inj metrogyl 100ml/IV/TID
Inj pantop 40mg IV/ BD
Tab Ciprofloxacin 400mg po/BD
Tab bactrim-DS/po/BD
Syrup grilinctus 15 ml po/BD
ORS sachets
Vitals monitoring
Temperature charting
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