57 year old female with fever since 1 month
December 27, 2022
Vitals
USG Abdomen
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57 year old female presented to the casuality with chief complaints of fever with chills since 1 month and loss of appetite since 1 month
HOPI : Patient was apparently asymptomatic 1 month back then developed Fever since 1 month associated with chills Which is episodic and intermittent low grade Which relived on medication 3 such episodes past 1 month 6 to 7 days of gap between the episodes
Evening rise of temperature only occasionally
No cough
No loss weight
C/o loss of appetite since 1 month
No complaints of pain abdomen
No complaints of burning micturition
No sob orthopnea/PND
No similar complaints in the past
PASTILLNESS
K/C/O epilepsy since 4 yrs on T Phenytoin 100 mg
K/C/O HTN since 4 years on T Amlodipine 10 mg
K/C/O Hypothyroidism since 4 years on T Levothyroxine 25 mcg
Not a k/c/o CAD,Asthama,TB
Personal history:
Decreased appetite takes mixed diet, regular bowel habits , normal micturition , no allergies
GENERAL PHYSICAL EXAMINATION
Patient conscious coherent cooperative
Moderately built and nourished
Pallor present
B/L pitting edema present till knee
Jvp raised
No, icterus, cyanosis, clubbing
Bp:160/100mmhg
RR-18cpm
PR-98bpm
TEMP-98.5F
Cardiovascular System : S1, S2 heard, no murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.
Central Nervous System : patient is conscious coherent and cooperative. Higher mental functions intact
Per abdomen : soft, non tender. Abdomen distended, hepatospleenomegaly present
Investigations :
Hemogram
Peripheral smear
USG inguinal region
Thyroid profile:
ECG:
Provisional Diagnosis:
Fever under evaluation, anemia under evaluation( ?secondary to blood loss) Denovo diabetic with k/c/o epilepsy, hypothyroidism,
Hypertension
Management :
1) Inj Monocef 1 gm/IV/BD
2) Inj neomol 100ml( if Temp > 101.1F)
3) Tab Dolo 650 mg /PO / TID
4) Tab Pantop 40 mg/PO/OD
5)Tab Zofer 4 mg /PO/SOS
6)Tab Metformin 500 mg/Po/OD
7)Tab Phenytoin 100 mg /Po/OD
8)Tab Amlodipine 10 mg /PO/OD
9)Tab Levothyroxine 25mcg /PO/OD
AMC Bed 4 :
Day 2
Unit 1
Dr. Zain (SR)
Dr. Raveen(PGY3)
Dr. Shashikala(PGY3)
Dr. Venkat Sai(PGY2)
Dr. Vivek(PGY1)
Dr. Prachethan (PGY1)
Dr.Nagarjuna ( intern)
Dr.kausalya (intern)
A 57 year old female came with complaints of
C/o fever since 1 month associated with chills
C/o loss of appetite since 1 month
K/c/o epilepsy since 4 yrs on T.Phenytoin 100mg
K/c/o hypertension since 4 yrs T Amlodipine 10 mg
K/c/o hypothyroidism since 4yrs on T. Levothyroxine 25 mcg
S
No fever spikes
Stools passed
O
Patient conscious, coherent,cooperative
Temp: 98F
BP:110/90 MMHG
PR:88 BPM
RR:20 CPM
CVS :S1,S2 +
CNS: NFND
Lungs : B/L air entry +
NVBS +
P/A soft non tender
Hepatomegaly +
A
Fever under evaluation anemia under evaluation( ?secondary to blood loss) with k/c/o epilepsy, hypothyroidism,
Hypertension
P
Inj neomol 100 ml ( if Temp > 101.1F)
INJ MONOCEF 1 GM / IV /BD
Tab Dolo 650 mg /PO/TID
Tab Pantop 40 mg /PO/OD
Tab ZOFER 4 MG /PO/SOS
Tab Metformin 500 mg/Po/OD
Tab Phenytoin 100 mg /Po/OD
Tab Amlodipine 10 mg /PO/OD
Tab Levothyroxine 25mcg /PO/OD
