75 year old with fever under evaluation
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Case seen by Unit 5 :
M. Sridevi (Intern)
Anjali Vishwas( Intern)
Mourya ( Intern)
Shriya ( Intern)
Dr. Praveen Naik Sir( Ass professor)
Dr. Natasha Mam
Dr. Zain Alam Sir
Dr. Sashikala mam
Dr. Shailesh Patil Sir
Here is the case I have seen :
Complaints and duration:
A 76 year old female presented to opd with complaints of fever since 1 year, complaints of vomiting s since 1 month, tingling sensation of bilateral upper and lower limb since 1 week, loss of appetite since 1 year
Patient was apparently asymptomatic 1 year ago, then she developed fever which is sudden in onset, gradually progressive ik nature, associated with chills and rigors, subsided on taking medication.
History of fever every month since 1 year which subsides on taking medication
Complaints of vomitings since 1 month ( 10 to 12 episodes in a day, bilious in type, containing food particles, is non projectile subsides on taking medication.
Complaints of tingling sensation of bilateal upper and lower limbs since 1 week
Complaints of loss of appetite since 1 year
History of burning micturition 1 month back
History of cough 15 days ago, associated with sputum, scanty in amount, no diurnal variation seen relieved with medication
History of lower abdominal pain diffuse , squeezing type, radiating to back 1 month ago relieved on Taking medication
No complaints of chest pain, palpitations, giddines, cold, cough, burning micturition, pedal edema, headache , loose stools, no dysuria
Past medical and surgical history:
K/c/0 diabetes since 14 years and is on T. Glycomet -GP2
Not a known case of HTN, Epilepsy, TB, thyroid abnormalities, any other systemic illness
No history of previous blood transfusion
History of cataract surgery in both eyes
Personal history: Appetite decreased since 1 year
Bowel movement s regular, micturition normal, no known history of allergies,
No addictions
Family history: not significant
Vitals at the time of admission:
Bp: 110/80 mm hg, PR:76 bpm, RR: 22 cpm
Investigation s:
Hemogram
Rbs: in normal range
Cbnaat report
FBS
Fasting lipid profile : showing elevated triglycerides
PlBS
Serum potassium: hypokalemia noted
Ophthalmology referral in view of Diabetic retinopathy changes
Usg abdomen and pelvis
Chest X ray
Rntcp report
HIV testing
Awaiting for blood culture and sensitivity reports
Diagnosis: FEVER UNDER EVALUATION ASSOCIATED WITH COUGH WITH SPUTUM
Treatment given:
Tablet PCM 500 mg PO/SOS
Temperature monitoring
Inj. HAI S/C (8 AM , ---2PM---8 PM)
Grbs monitoring( before breakfast, 2 hrs after breakfast, before lunch, 2 hrs after lunch, before dinner, 2 hrs after dinner, at 2 am in the morning)
Tablet Doxycycline 500 mg /BD/PO
Day. 2 INVESTIGATION S
ESR: elevated
Awaiting for blood culture and sensitivity reports
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