65 year old female with fever since 1 week that is associated with chills and generalised weakness
65 YEAR OLD FEMALE WITH FEVER SINCE 1 WEEK THAT IS ASSOCIATED WITH CHILLS AND GENERALISED WEAKNESS
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.
A 65 year old female, homemaker by occupation, hailing from Miryalaguda came to the OPD with chief complaints of fever since 1 week that is associated with chills and generalised weakness.
History of present illness : The patient was apparently asymptomatic 5 years back, then she visited the hospital for knee pain during which she was diagnosed with hypertension. She is now on medication for HTN ‐ Tablet Telmisartan 40mg ‐ OD.
Then on a regular checkup to the hospital, the patient was diagnosed with DM 4years back. She was given Tablet Metformin but stopped 6 months back as suggested by the doctor after checking her blood sugar levels which were low.
6 months back the patient also went to the hospital with complaints of pedal edema upto the knees since 1 month and also foul smelling urine. The patient was diagnosed with CKD then. On evaluation in the hospital they were informed that the size of the kidneys were reduced and there was protein in the urine.
After evaluation the patient was given medication for the kidney pathology which she used till 3 months ago. The patient then stopped the medication without consulting the doctor as there were no symptoms.
Now the patient complaints of high grade fever since 1 week that is associated with chills and generalised weakness. The fever showed nocturnal variation and decreased on taking medications.
She is not able to get up from her bed to do her normal activities.
Past history : H/O HTN since 5 years
H/O DM since 4 years
No H/O epilepsy, TB, thyroid disorders, coronary artery disease, asthma.
Personal history : 10 years back she used to work as a farmer in the fields, after which she stopped farming and now she just stays at home.
Diet ‐ mixed
Appetite ‐ decreased
Sleep ‐ adequate
Bowel and Bladder movements ‐ regular
Addictions ‐ none
General Examination : The patient is drowsy but easily arousable and follows command, moderately built and nourished.
Pallor is present.
Pedal edema is present ‐ pitting type
Icterus, cyanosis, clubbing and generalised lymphadenopathy are absent.
21‐02‐2022
Temperature ‐ 101F
BP ‐ 130/90 mmHg
RR ‐ 22 cpm
PR ‐ 90 bpm
SpO2 ‐ 98% at room air
GRBS ‐ 88 mg/dl
22‐02‐2022
Temperature ‐ 100F
BP - 130/90 mmHg
RR ‐ 20 cpm
PR ‐ 92 bpm
SpO2 ‐ 98 % at room air
GRBS ‐ 99 mg/dl
Systemic Examination :
CVS :
On palpation ‐
• Apex beat was felt in the 5th intercostal space medial to the mid clavicular line.
• JVP was normal
• No precordial bulge
• No parasternal heave
On auscultation ‐ S1, S2 heard , no murmurs
RS :
On inspection ‐
• Chest is bilaterally symmetrical
• Expansion of chest: Equal on both sides
• Position of trachea: Central
• No visible scars, sinuses, pulsations
On palpation :
• Expansion of chest was equal on both sides.
• Position of trachea: Central
• Tactile Vocal Fremitus: resonant note was felt.
On percussion: all lung areas were resonant
On auscultation :
• Bilateral air entry was present, normal vesicular breath sounds were heard.
• Vocal resonance: resonant in all areas
P/A : soft, non tender, no organomegaly, no distension, bowel sounds heard.
CNS :
Higher mental functions :‐
• The patient was drowsy.
• Speech and language are normal.
• Memory is intact.
Cranial nerve examination :‐
All cranial nerves are intact and functioning.
Motor System Examination :‐
• Normal bulk in upper and lower limbs
• Normal tone in upper and lower limbs
• Normal power in upper and lower limbs
• Gait could not be examined as the patient is drowsy and not able to stand.
Reflexes :‐
R L
BICEPS +2 +2
TRICEPS +1 +1
SUPINATOR +1 +1
KNEE +1 +1
ANKLE +2 +2
PLANTAR FLEXION present in both the lower limbs.
Sensory System Examination :‐
Normal sensations are felt in all the dermatomes.
Cerebellar tests :‐
Finger‐nose incoordination present.
Knee‐heel incoordination present.
Glasgo ‐ Coma Scale ( GCS ) : E3 V1 M6
E3 = eye opening on command
V1 = no verbal response
M6 = motor response on command
Pupils = NSRL ( Normal in Size and Reactive to Light )
Investigations :
FEVER CHART
ECG
USG
COLOUR DOPPLER 2D ‐ ECHO
Treatment :
1) Injection Pantop 40mg IV/OD
2) Injection Zofer 4mg IV/SOS
3) Injection Neomol 100ml IV/TID
4) Injection optineurin 1ampoule in 100 ml NS/IV/OD
5) Tablet Ecospirin AV 75/20 PO/HS
Comments
Post a Comment