A 60 year old male came with chief complaint of fever and headache

A 60 year old male came with chief complaint of fever and Head ache

This is an oneline e-blog depicting patient's de-identified data centred approach for learning medicine. This log has been created after taking concert from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them 

Chief complaint : A 60 year old male patient came to casualty with a complaint of fever with chills and head ache since 1 week 

History of present illness :
A 60 year old male patient who was farmer by occupation was apparently asymptomatic 1 week back then he notice fever with chills and headache, relieved on taking medication and he visited other hospital before coming here they gave a report positive for widal test 
Uncontrolled diabetes (2 days)

History of past illness :
History of diabetes (on medication since 18 years)
No history of hypertension, asthma,TB,Epilepsy, Thyroid

Personal History :
Married
Diet : vegetarian 
Appetite : Normal
Sleep : Adequate 
Allergies : No
Bowel movements : Regular 
Micturition : Burning ( since 1 week )
Addictions : No

Family History : 
No relevant family history

General Examination : 
Patient is conscious, coherent cooperative to time, place and person
No H/o cyanosis ,pallor,icterus,clubbing,lymphadenopathy 
Built: Moderately Bulit

Vitals :
Temp : 97.6 F
Rp : 20
PR : 90
BP : 110/ 70

Systemic Examination : 
CVS : No thrills and Cardiac murmurs 
Sounds : S1,S2 +
RS : No Dyspnoea, Wheeze 
Abdomen - shape Scaphoid 
CNS : conscious, speech normal 
No neck stiff Ness

Diagnosis 
Viral pyrexia and Uncontrolled diabetes 

Investigations 
Complete urine examination 
 Hemogram 
 Ultrasound 
 Random blood   
 Treatment 
Day -1
 Day -2 
 

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