55M pyrexia postop
55/M Pyrexia under evaluation with cervical laminectomy 2 months back
June 05, 2023
Chief complaints:
Patient came with cheif complaints of burning type of sensation of whole body since 1 week.
Fever since 1 day
HOPI:
Patient was apparently asymptomatic 2 months back after which he had an RTA during which he had cervical cord stenosis and was operated with cervical cord laminectomy i/v/o weakness of both upper and lower limbs. After which patient was on physiotherapy and power improved gradually.Now patient had h/o burning sensation and numbness of whole body( paresthesia).
He also have complaints of fever since today afternoon associated with chills , relieved on medication.
H/o of burning micturition since 4-5 days
No H/o decreased sensations
No h/o bowel and bladder incontinence.
No h/o seizure activity
No H/O cold, cough, sore throat
No H/o nausea , vomiting, pain abdomen
No H/o loose stools
PAST HISTORY:
Not a k/c/o dmII, htn, thyroid disorders,asthma,epilepsy
GENERAL EXAMINATION:
Patient is conscious, coherent
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema,
Temp: 101.5 degree F
Pr: 98bpm
Rr: 20cpm
Bp:130/70mm Hg
Grbs:151mg/dl
SYSTEMIC EXAMINATION
Cvs:S1 S2 heard , No murmurs
Rs: BAE +, NVBS
P/A: NT
CNS:
Tone UL LL
R N N
L N N
Power : UL LL
R 2/5 4/5
L 3/5 4/5
Reflexes - B T S K A P
RT- +3 +3 2+ 3+ 3+ F
LT- +3 +3 2+ 3+ 3+ F
DIAGNOSIS:
Pyrexia under evaluation with cervical laminectomy 2 months back
TREATMENT:
1. Inj Neomol 1 GM iv/sos ( if temp > 101 F)
2. Inj Monocef 1 GM iv/ bd
3. Inj optineuron 1 amp in 500ml NS /OD
4. Tab dolo 650mg Po/ Sos
5.tab pregabalin 75mg po/Hs
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