feverprojr LEPTO 26/F 202310413

 leptospirosis- 20230309679



VIRAL PYREXIA WITH THROMBOCYTOPENIA

WITH AKI(ACUTE KIDNEY INJURY)

WITH URINARY TRACT INFECTION

?HUS SECONDARY TO GRAM NEGATIVE BACILLI ? E.COLI

?LEPTOSPIROSIS ?CSVT SECONDARY TO APLA

WITH PAST H/O ASTHMA SINCE 2 YEARS

Case History and Clinical Findings

COMPLAINTS OF FEVER ASSOCIATED WITH CHILLS AND RIGORS SINCE 5 DAYS.

C/O SOB SINCE 5 DAYS

HISTORY OF PRESENT ILLNESS:

PATIENT WAS APPARENTLY ALRIGHT 5 DAYS BACK. SHE HAD FEVER WHICH IS LOW GRADE, INTERMITTENT, ASSOCIATED WITH CHILLS AND RIGORS WITH EVENING RISE OF TEMPERATURE AND RELIEVED BY TAKING MEDICATION.

C/O SOB SINCE 5 DAYS (GRADE II)

NO ORTHOPNEA, NO PND, NO PEDAL EDEMA.


H/O VOMITINGS. 2 EPISODES YESTERDAY, NON PROJECTILE, NON BILIOUS, FOOD AS CONTENT, NON FOUL SMELLING.

NO H/O LOOSE STOOLS, CHEST PAIN, PALPITATIONS, SWEATING, NO PAIN ABDOMEN

BURNING MICTURITION PRESENT

HISTORY OF PAST ILLNESS:

H/O OF DELIVERY BY LSCS ON 01/02/2023

H/O ? ASTHMA SINCE 2 YEARS (USING UNKNOWN INHALER)

N/K/C/O HTN, TB, DM, EPILEPSY, CVA, CAD

OBTETRIC HISTORY:

AGE AT MARRIAGE: 23

PARA 2

INTRA UTERINE DEATH : 1

NO OF LIVING CHILDREN : 1

GENERAL EXAMINATION:

ICTERUS ; PRESENT

NO SIGNS OF PALLOR, CYANOSIS, CLUBBING, LYMPHADENOPATHY, OEDEMA

VITALS:

TEMPERATURE: 97.5

BP: 110/70

PR: 134/MIN

RR: 22/MIN

GRBS: 109 MG/DL

SYSTEMIC EXAMINATION

CVS: S1 S2 HEARD, NO MURMURS

RS: DYSPNEOA +, NVBS

ABDOMEN: SOFT, TENDER

CNS: PATIENT IS CONSCIOUS

NO SIGNS OF MENINGEAL IRRITATION

NFND

1 SDP TRANSFUSION DONE ON 07/03/2023 AT 3.15 PM


COURSE IN THE HOSPITAL;

PATIENT CAME WITH ABOVE MENTIONED COMPLAINTS ON CLINICAL EVALUATION AND LABORATORY INVESTIGATIONS PATIENT WAS EVALUATED AND FOUND TO HAVE DERANGED RENAL PROFILE-ACUTE KIDNEY INJURY, ANEMIA, THROMBOCYTOPENIA AND PROVISIONALLY DIAGNOSED` AS ?HEMOLYTIC UREMIC SYNDROME(BLOOD CULTURE SHOWED GRAM NEGATIVE BACILLI CULTURE SENSITIVITY REPORT AWAITED) /? VIRAL PYREXIA WITH THROMBOCYTOPENIA. PATIENT COMPLAINED OF HEADACHE, BLURRING OF VISION AND MRI BRAIN WAS ADVISED IN VIEW OF CEREBRAL VENOUS SINUS THROMBOSIS. IN VIEW OF PAST HISTORY OF APLA SYNDROME(ANTI CARDIOLIPIN ANTIBODY IgG POSITIVE) FETAL LOSS PATIENT WAS ADVISED CARDIOLIPIN ANTIBODY IgG ANTIBODIES. IN VIEW OF DERANGED RENAL HEPATIC PARAMETERS AND THROMBOCYTOPENIA LEPTOSPIROSIS WAS SUSPECTED AND ADVISED LEPTOSPIRA IgM WAS ADVISED.

Investigation

ULTRASOUND REPORT

IMPRESSION:

MILD HEPATOMEGALY

BORDERLINE SPLENOMEGALY

GALL BLADDER WALL EDEMA WITH INCREASED WALL THICKNESS

2D ECHO:

IMPRESSION:

NO MR/ AR/ TR

NO RWMA. NO AS/MS

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION, NO PAH/PE

07/03/2023

HB; 10.1

TLC; 11200

RBC; 3.45

PCV; 30.3

PLATELETS; 20000


HB; 7.7

TLC; 8000

RBC; 2.62

PCV; 22.1

PLATELETS; 20000

09/03/2023

HB; 6.9

TLC; 6400

RBC; 2.38

PCV;21.7

PLATELETS; 12000

Treatment Given(Enter only Generic Name)

1. IV FLUIDS NS @75ML/HOUR

2. INJ ZOFER 4MG /IV/BD

3. INJ PAN 40 MG /IV / OD

4. TAB. PCM 650 MG/ PO/ SOS

5. INJ NEOMOL 2 GM IV / SOS

6. INJ. MONOCEF 1 GM IV/BD X 3 DAYS

7. TAB. RANTAC 150 MG PO/OD

8. INJ. LASIX 40 MG IV/STAT

9. VITALS MONITORING 4TH HOURLY

10. WATCH FOR HYPOTENSIVE SYMPTOMS






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