A 60 yr old male patient came with complaint of fever and headache

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

CHEIF COMPLAINT :  A 60 yr old Male patient came to the causality  with a complaint of fever with chils and headache since 1week
HISTORY OF PRESENT ILLNESS  :
A 60 yr old male patient who is farmer by occupation  was apparently asymptomatic
1week back then he noticed fever with chills ,headache from1week and relived on taking medication and he visited other hospital before coming here they gave a report positive for widal test
Uncontrolled  diabetes ( 2days)
HISTORY  OF  PAST ILLNESS  :
H/o diabetes ( on medication  since18 yrs)
No h/o hypertension, asthma ,tb epilepsy,thyroid 
PERSONAL HISTORY:
Married
Diet : vegetarian 
Sleep : adequate
Allergies : no
Bowel movements: regular 
Micturation : burning (1week)
Addictions: no
FAMILY HISTORY  :
No relevant family history 
GENERAL EXAMINATION:
Patient is conscious, coherent,coperative
and well oriented to time place and person
No h/o cyanosis,clubbing,pallor,icterus ,
lympadenopathy
Built: moderate
Vitals:
Temp: 97.6°F
RR :20
Bp: 110/70
PP :90
SYSTEMIC EXAMINATION  :
CVS : no thrills $cardiac murmurs
Sounds : s1 s2 +
RS : no dysponea $wheeze 
Abdomen:
Shape :scaphoid
CNS : conscious,speech normal
no neck stiffness 
DIAGNOSIS  :
Viral pyrexia and uncontrolled  diabetes
INVESTIGATIONS :
Hemogram :
Complete  urine examination 
Ultrasound 

Random Blood sugar: 44O
TREATMENT  :
Day 1
day 2

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