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80 year old female with chief complaints of high grade fever since one week decreased urine output since one week .
HISTORY OF PRESENTING ILLNESS
patient was apparently asymptomatic one week ago when she developed high grade fever remittent type ,insidious in onset and gradually progressing in nature relieved on medication (paracetamol) and no aggravating factors, assosiated with generalised weakness ,headache since one week which is insidious on onset gradually progressive ,associated with decreased urine output since one week and loose stools since two days ,three episodes of loose stools on 5/01/2023 decreased appetite since one week .
no history of nausea,vomiting,burning micturation
PAST HISTORY
Not a known case of HTN ,DM, TB, Asthma, thyroid abnormalities,psychiatric illness,epilepsy
Family history
No similar complaints in family
Drug history
None
Surgical history
None
Personal history
Appetite - normal but decreased since one week
DIET - mixed
BOWEL AND BLADDER -decreased frequency since one week and loose stools since two day (3 episodes of loose stools on 5/1/23)
SLEEP -adequate
ADDICTIONS -none
ALLERGIES -none
General examination
Pt is conscious ,coherent and co operative ,well oriented to time, place and person
Moderately built and moderately nourished .
No signs of pallor icterus cyanosis clubbing lymphadenopathy pedal edema
At presentation on 4/01/2023
Temp -104’F
BP -100/60 mmhg
HR-145bpm
RR-24 cpm
SpO2-98% at room air
(On 5/01/2023 5:30pm )
Temp -102’F(tepid sponging was done at 5:30 pm )
BP -80/60 mmhg
HR-82bpm
RR-22 cpm
SpO2-97% at room air
(On 6/1/2023)
Temp -98.7’F
BP- 90/50mmhg
HR- 120bpm
RR - 16cycles/min
SpO2 -97% at room air
On(6/1/23-3.30pm)
Temp-103’F
BP-70/50mmhg
HR-122bpm
SYSTEMIC EXAMINATION
CNS
No neurological focal deficits
Higher mental functions are intact
CVS
On palpation
Apex beat was felt in the 5 th inter coastal space medial to the mid clavicular line
Jvp was normal
No parasternal heave
-S1,S2 heard , no murmurs
RESPIRATORY SYSTEM EXAMINATION
On inspection
Chest is b/l symmetrical
Expansion of chest equal on both sides
Position of trachea -central
No visible scars sinuses
On palpation
Expansion of chest was equal on both sides
Position of trachea -central
Tactile vocal fremitus -was felt
On percussion
all lung areas resonant
On auscultation
BAE + crepitations +
Vocal resonance - all areas resonant
PER ABDOMEN EXAMINATION -
soft ,tender on palpation and no organomegaly
Umbilicus -Inverted
bowel sounds - minimally heard
PROVISIONAL DIAGNOSIS
- fever in evaluation , sepsis with hypovolemia ?dengue?INVESTIGATIONS
Serology for HBsAg, HIV, HCV - negative
Blood Urea
Serum creatinine
Serum electrolytes
LFT
DENGUE SEROLOGY
HEMOGRAM GRBS
ECG
SINUS TACHYCARDIA- due to hyper pyrexia
COMPLETE URINE EXAMINATION
Inference from investigations-
Blood urea creatinine are raised , pt is loosing albumin in the urine hence the low protein in serum ,bilirubin is elevetaed ,hyponatremia and k+ is borderline at 36
Thrombocytopenia (80,000 platelets)
FINAL DIAGNOSIS
viral pyrexia with thrombocytopenia
hypovolemic shock secondary to sepsis
TREATMENT
FLUIDS - RINGER LACTATE
NORMAL SALINE (100ml /hr )
TAB paracetamol 650 mg TIV peroral
IV NEOMOL 1gm ASAP if fever >101*F
INJ OPTINEURON 1 ampule in 500 ml NS OD
MONITOR FLUID INPUT AND URINE OUTPUT
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