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 

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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. 

VITALS  :

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

22‐02‐2022 CBP

ECG 

USG

COLOUR DOPPLER 2D ‐ ECHO

X RAY

Provisional diagnosis  : CKD patient with pyrexia and hyponatremia both under evaluation. 

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