fever projr unclassified 73/F 202243893

 unclassified : 20221029418 

Diagnosis

PYREXIA OF UNKNOWN ORIGIN

(?)ATYPICAL PNEUMONIA

(?)PULMONARY TUBERCULOSIS

wITH RIGHT UPPER AND MIDDLE LOBE CONSOLIDATION WITH COLLAPSE

WITH UNCOMPLICATED UTI(TREATED OUTSIDE)

WITH RIGHT MILD PLEURAL EFFUSION

HEART FAILURE WITH PRESERVED EJJECTION FRACTION

ANEMIA OF CRONIC DISEASE

NON OLIGURIC AKI RESOLVING

NEPHRITIC RANGE PROTIENURIA

WITH K/C/O HYPERTENSION AND DIABETES MELLITUS

Case History and Clinical Findings

Chief complaints:

Fever since 1month (sep15th)

Burning micturition for 10days (sep15th -25th)

Abdominal pain since 1month

Decreased appetite since 20 days

HISTORY OF PRESENTING ILLNESS:

A 72 year post menopausal female , came to casualty with complaints of fever since sep15th ( 36th day of illness). Fever was high grade with evening rise in temperature associated with chills and rigors, not associated with nausea and vomiting/headache/cold/cough . She was treated with oral medicines on day 2 of illness,But fever dint subside . Not associated with loose stools /blood in stools

On 2nd October (17th day of illness ) she was given IV antibiotics for 2 days , and was on antipyretics

From 9th October she had feverspike , she consulted a doctor, she was started on inj. Magnexforte and Tab. Farepeneum 200mg for a week

“presented to outside hospital with fever , right hypochondriac pain and nausea , she was clinically as SEPSIS WITH MODS, surgical opinion was taken and adviced for lap cholecystectomy for acalculous cholecystitis, but they refused., advised to get CECT abdomen but she got chills after a test dose of contrast. The physician thought of melioidosis and started on Meropenem .Blood and urine cultures were not done

As told by the doctor

On 19/10/22, they are referred to our hospital

PAST HISTORY:

K/c/o Hypertension since 20yrs and was on Amlodipine 5mg + atenolol 50mg

K/c/o Type 2 diabetes mellitus since 22 yrs and is on Tab. Glimepiride 2mg+Tab. Met Formin 500mg

Surgery: Right PFN 11yrs ago

PERSONAL HISTORY:

Decreased appetite takes mixed diet, irregular bowels( Type 1 Bristol stool) ,normal micturition , no allergies

Family history: not significant

MENSTRUAL HISTORY:

Age of menarche - 15yrs

LMP- post menopausal status

OBSTETRIC HISTORY:

Age at marriage-12yrs

Gravida:3 (all 3 are Full term NVD)

1st male , 2nd female - died

3rd - female alive

GENERAL PHYSICAL EXAMINATION

Patient conscious coherent cooperative

Moderately built and nourished

No, icterus, cyanosis, clubbing, lymphadenopathy

Pedal edema upto lower end of tibia

Vitals

Bp:160/90mmhg

RR-24cpm

PR-98bpm

SPO2-94%

GRBS-343mg/dl (inj. HAI 12 units given)

TEMP-98.3F

SYSTEMIC EXAMINATION:

CVS: S1 S 2Heard

RS: SOB GRADE 2 MMRC, vesicular breath sounds

PER ABDOMEN: scaphoid, nontender, BS +

CNS: NFND

COURSE IN HOSPITAL:

A 72yr old post menopausal female presented to our casualty with complaints of fever since sep15th ( 36th day of iliness). high grade continuous type associated with chills and rigors

not associated with nausea and vomiting/headache/cold/cough.

H/o Early morning( 12-2am ) fevers

With every 2 days

And continuous fevers through out the day since 4-5 days

History of UTI was present and subsided with no longer symptoms of burning micturition, increased frequency and urgency

She was treated with oral medicines on day 2 of illness and fever hadn't subsided. It was not associated with loose stools /blood in stools

On 2nd October (17th day of illness ) she was given IV antibiotics for 2 days, and was on antipyretics

From 9th October she again had a fever spike, she consulted a doctor, she was started on in. Magnexforte and Tab. Farepeneum 200mg for a week

'presented to outside hospitalwith fever, right hypochondriac pain and nausea, she was clinically as SEPSIS WITH MODS, surgical opinion was taken and adviced for lap cholecystectomy for acalculous cholecystitis, but they refused. advised to get CECT abdomen but she got chills after a test dose of A contrast. The physician thought of melioidosis and started on Meropenem Blood and urine cultures were not done

As told by the doctor

On 19/10/22, they are referred to our hospital

The patient and her attendee have been explained regarding the condition of the patient and need for BAL through the bronchoscopy procedure ,inspite of explaining the benefits and diagnostic approach the patient and her attendee has been refused for the same and have not given consent

Investigation

blood culture(-ve) ,automated blood culture(-ve) and stool for occult blood(-ve) was also sent. Hb - 8.9gm/dl,total count-12,100.

24 hour urine sample showed, volume-1900ml,protiens-2280 mg/day

21/10/22

HRCT ,showed consolidation in anterior segment of right lung upper lobe and right middle lobe- infective,mild right pleural effusion.after taking the consent right sided pleural tap was done and sent for investigations,CBNAAT(-ve). pleural fluid showed ,sugars-75mg/dl ,protiens-3.1GM/dl,LDH- 180IU/L i.e.TRANSUDATE

usg abdomen showed gallbladder with microcalculi,right simple renal calculi,raised echogenecity in right kidney,grade 1 fatty liver,liver-14.7cm,cbd-6mm,spleen-10.2cm,right kidney 11.i x 5.2cm,left kidney 11.2x5cm,aorta IVC-obscured

22/10/22

REFFERED TO PULMONOLOGIST,I/V/O CT finding(right middle lobe collapse with effusion),they advised for ana profile,,plan for bronchoscopy(BAL)

GYNECOLOGY REFFERAL to rule out any PID ,adviced for usg pelvis which showed ,tiny internal echos noted in urinary bladder ,urinary bladder distened, wall thickness normal,uterus- 5.2x2.7cm,endometrial thickness-4mm,myometrium normal,ovaries not visualised

patient is dischared in a stable condition

Treatment Given(Enter only Generic Name)

Allow oral fluidsINJ. NEOMOL 1gm/iv/sosTAB. DOLO 650mg/po/TIDvitals monitoring 1 hrlyTab. AMLODIPINE 5mg + ATENOLOL 50mg /po/odINJ. HAI7 points GRBS ProfileINJ.CEFTRIAXONE 1GM IV BD for 5daysTAB.DOXY 100MG PO/BD for 5 daysINJ.LASIX 40MG/IV/BDTAB.ULTRACET SOSIVF 1NS WITH OPTINEURON AT 75ML/HR

Advice at Discharge

1.INJ.HUMAN ACTRAPID INSULIN/SUBCUTANEOUS / THRICE DAILY

( 8U AT 8AM -8U AT 1PM -6U AT 8PM)

2.TAB.TELMA 40MG /PER ORAL/ ONCE DAILY

3.TAB.TAXIM-O 200MG/ PER ORAL/ TWICE DAILY FOR 2 DAYS

4.TAB.DOXY 100MG /PER ORAL/ TWICE DAILY FOR 9DAY

5.TAB.LASIX 40MG/PERORAL/TWICE DAILY FOR 3 DAYS

6.SYP. ARYSTOZYME 15ML/PERORAL/THRICE DAILY