fever projr malaria 70/F 328687

 malaria 202328687

Diagnosis

1)ACUTE SEVERE PAN EROSIVE GASTRITIS

2)DENOVO HTN WITH HYPERTENSIVE URGENCY(RESOLVED).

3)ACUTE FEBRILE ILLNESS.

4)?ENTERIC FEVER.

5)?CLINICAL MALARIA.

6)ORTHOSTATIC HYPOTENSION?AUTONOMIC DYSFUNCTION.

7)HYPOKALEMIC SECONDARY TO GI LOSSES.

8) ? PYREXIA OF UNKNOWN ORIGIN

Case History and Clinical Findings

PATIENT CAME WITH CHEIF COMPLAINTS OF VOMITINGS SINCE 3-4DAYS.

HOPI:-PATIENT WAS APPARENTLY ASYMPTOMATIC 3DAYS BACK.SHE THEN HAD VOMITINGS 6-7 EPISODES SINCE 3DAYS WATERY,NON-PROJECTILE,NON-BILIOUS,NON- MUCOID,NOT BLOOD STAINED WITH FOOD PARTICLES AS CONTENTS.

-C/O PAIN ABDOMEN IN HYPOGASTRIUM.

-NO C/O CHESTPAIN,SOB,PALPATATIONS,PEDAL EDEMA,FACIAL PUFFINESS,ORTHOPNOEA,PND.

C/O CONSTIPATION SINCE 5-6 YEARS PASSES STOOLS ONCE IN 2-3 DAYS.

-C/O DECREASED URINE OUTPUT SINCE 1WEEK(LOW ORAL INTAKE)

-USUALLY NORMAL URINE OUTPUT.

-C/O GENERAL BODY PAINS.

PAST HISTORY:-NOT A K/C/O DM,HTN,TB,EPILEPSY,CVA,CAD,THYROID DISORDERS AND ASTHMA.

GENERAL EXAMINATION:-

PATIENT IS CONCIOUS,COHERENT AND COOPERATIVE TO TIME,PLACE AND PERSON.

VITALS:-

TEMP-98.2 F

BP:120/ 70 MMHG

PR :98 BPM

RR:16 CPM

SPO2:99% ON RA

SYSTEMIC EXAMINATION:-

CVS:S1S2+ ,NO MURMURS

RS:BAE+,NVBS.

CNS :NFND

COURSE OF ADMISSION:-

70YR OLD FEMALE PRESENTED WITH C/O VOMITINGS SINCE 3DAYS(6-7EPISODES) WATERY,NON-PROJECTILE AND FOOD PARTICLES AS CONTENTS.C/O NAUSEA SINCE 3DAYS.AND ON EXAMINATION PATIENT VITALS ON ADMISSION ARE BP120/70MMHG,PR- 98BPM,RR-16CPM,TEMP-AFEBRILE.ON 1/7/2023 AT 4:00PM PATIENTS BP WAS FOUND TO HAVE 200/100MMHG GIVEN INJ.LABETALOL 5MG IV/STAT (@4:30PM) THEN BP @6:00PM IS 120/80MMHG,PR-118BPM.BP WAS HIGH AND ANTI-HYPERTENSIVE MEDICATIONS WERE ADDED (DIAGNOSED AS DENOVO HTN).

1)TAB.TELMA 40MG PO/OD

2)TAB.MET-XL 25MG PO/OD

3)TAB.CINOD 10MG PO/OD

SINCE 2/7/2023,FEVER SPIKES WERE PRESENT AND C/O NAUSEA(DECREASED),AND WAS MANAGED CONSERVATIVELY WITH I.V.FLUIDS AND I.V.ANTIBIOTICS.PATIENT VITALS AT TIME OF DISCHARGE BP-160/90MMHG ,PR-116BPM ,RR-20CPM AND TEMPERATURE-99.2F. PATIENT IS HAEMODYNAMICALLY STABLE AT TIME OF DISCHARGE.

OPTHALMOLOGY REFFERAL:-(4/7/2023)

I/V/O RAISED ICT AND HYPERTENSIVE RETINOPATHY

FINDINGS:-NORMAL FUNDAL STUDY

ADVICE:- 1)E/O CIPLOX QID.

2)REVIEW TO OPHTHALMOLOGY OPD FOR ANY EYE DISCHARGE.

GASTROENTEROLOGIST REFFERAL:-(7/7/2023)

I/V/O ?ACUTE SEVERE GASTRITIS.

FINDINGS:-ESOPHAGES-LAX IN LES

STOMACH-EROSIONS IN FUNDUS AND ANTRUM

DUODENUM-D1 AND D2-NORMAL.

IMPRESSION:- SEVERE EROSIVE PAN GASTRITIS.

ADVICE:-INJ.PANTOPRAZOLE 80MG/IV/STAT BOLUS.

FOLLOWED BY INJ.PANTOPRAZOLE 80MG IV INFUSION/HR FOR 24HRS.

THEN INJ.PAN 40MG IV/BD.

IF VOMITINGS PERSISTS MORETHAN 72HOURS, THEN PLAN FOR CT-ABDOMEN.

CT - ABDOMEN IN PELVIS DONE - NORMAL.

REVIEW REFERRAL FROM GASTROENTEROLOGIST TAKEN - ADVICED FOR NEUROPHYSICIAN REFERRAL.

PATIENT AGAIN C/O FEVER SINCE MORNING(11/7/23) HIGH GRADE ,ASSOCIATED WITH CHILLS AND RIGORS,.

Investigation

SERUM ELECTROLYTES:- (30/6/2023)

SODIUM:138mEq/L

POTASSIUM:3.6mEq/L

CHLORIDE:98mEq/L

CALCIUM IONIZED:1.19mmol/L

SERUM CREATININE:- 1.2mg/dl

HEMOGRAM:-(30/6/23)

HB-13.8 GM/DL

PLT COUNT-2.73LAKHS/CUMM

TLC-9000CELLS/CUMM

RBC-4.79 MILLION

BLOOD UREA:-16mg/dl

RBS:-152MG/DL

BLOOD GROUPING:B

RH TYPING:POSITIVE

2 D ECHO(1/7/23):-

TRIVIAL AR NO MR/TR

NO RWMA ,NO AS/MS,SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION MILD LVH

DIASTOLIC DYSFUNCTION + NO PAH/PE

USG(1/7/23):-

FINDINGS:-

-E/O FEW CYSTS NOTED IN RIGHT KIDNEY LARGEST MEASURING 24X24MM IN LOWER POLE.

-E/O 5MM CALCULUS NOTED IN UPPER POLE OF RIGHT KIDNEY.

-VISUALISED BOWEL LOOPS APPEARS NORMAL AND SHOW NORMAL PERISTALISI AND NO DILATATIONS.

IMPRESSION: 1)GRADE II FATTY LIVER

2)RIGHT RENAL CALCULUS

3)RIGHT RENAL CORTICAL CYSTS

URINE FOR C/S - NO GROWTH (3/7/23)

BLOOD C/S - NO GROWTH AFTER 24HRS OF AEROBIC INCUBATION.(6/3/23)

ON 1/7/2023:-

HbA1c:-6.7%

LFT:-

TOTAL BILURUBIN-1.57MG/DL

DIRECT BILIRUBIN-0.86MG/DL

AST-43IU/L

ALT-14IU/L

TOTAL PROTEINS-5.3GM/DL

ALBUMIN-2.86GM/DL

A/G RATIO-1.17

CUE:-

COLOUR-PALE YELLOW

APPEARANCE-CLEAR

REACTION-ACIDIC

SP.GRAVITY-1.010

ALBUMIN+

SUGAR-NIL

BILE SALTS-NIL

BILE PIGMENTS-NIL

PUS CELLS:2-3

EPITHELIAL CELLS :2-3

RED BLOOD CELLS-NIL

CRYSTALS CASTS-NIL

AMORPHOUS DEPOSITS-ABSENT

OTHERS-NIL

ON (2/7/2023):-

RFT:-

UREA-18MG/DL

CREATININE-1.0MG/DL

URIC ACID-6.2MG/DL

SODIUM:138mEq/L

POTASSIUM:3.5mEq/L

CHLORIDE:102mEq/L

CALCIUM:9.8mmol/L

PHOSPHOROUS-4.0MG/DL

HEMOGRAM:-ON (3/7/2023)

HB-12.6 GM/DL

TC-7,800CELLS/CUMM

NEUTROPHILS-50

LYMPHOCYTES-40

EOSINOPHILS-02

PCV-37.5

MCV-89.7

MCH-30.1

MCHC-33.6

RBC COUNT-4.18MILLIONS/CUMM

PLATELET COUNT-2.19LAKHS/CU.MM

URINE CULTURE:-0-1/HPF PUS CELLS SEEN

-NO GROWTH

ON (4/7/2023):-

HB-11.9GM/DL

TC-8,300CELLS/CUMM

NEUTROPHILS-58%

LYMPHOCYTES-30%

EOSINOPHILS-05%

MONOCYTES-07%

BASOPHILS-00%

PCV-35.4vol%

MCV-86.3fl

MCH-29.0pg

MCHC-33.6%

RBC COUNT-4.10MILLIONS/CUMM

PLATELET COUNT-1.76LAKHS/CUMM

ON 11/07/23

HB-10.9GM/DL

TC-5,500CELLS/CUMM

NEUTROPHILS-55%

LYMPHOCYTES-25%

EOSINOPHILS-05%

MONOCYTES-15%

BASOPHILS-00%

PCV-32.4vol%

MCV-84.3fl

MCH-28.3pg

MCHC-33.6%

RBC COUNT-3.85MILLIONS/CUMM

PLATELET COUNT-1.50LAKHS/CUMM

Treatment Given(Enter only Generic Name)

1)I.V FLUIDS 2.NS AND RL 50ML/H

2)INJ.ZOFER 4MG IV/BD

3)INJ.PAN 40MG IV/BBF.

4)TAB.TELMA 40MG PO/OD

5)TAB.MET-XL 25MG PO/OD

6)TAB.CINOD 10MG PO/OD

7)INJ.METOCLOPRAMIDE 10MG IV/OD

8)INJ.FALCIGO 120MG /IV/OD

9)TAB.DOXYCYCLINE 100MG PO/BD

10)INJ.MONOCEF 1GM IV/BD X 7DAYS

11)TAB.DOLO 650MG PO/QID

12)SYP.POTCHLOR 15ML/PO/TID X 1 DAY.

13)TAB.REDOTIL 100MG PO/BD X 1DAY(8AM----------------8PM).

14)INJ.KCL 2AMP IN 500ML NS/OVER/4-5HRS.

Advice at Discharge

1)TAB.ZOFER 4MG PO/TID X5DAYS.

2)TAB.TELMA 40MG PO/OD AT 8AM X5DAYS.

3)TAB.MET-XL 25MG PO/OD AT2PM X5DAYS.

4)TAB.CINOD 10MG PO/BD AT 8AM AND 8PM X5DAYS.

5)TAB.PAN 40MG PO/BD X 5DAYS.

6.)E/O CIPLOX QID.