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CONSENT AND DEIDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever
CHIEF COMPLAINTS
80 year old female with chief complaints of high grade fever since one week decreased micturation 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 ,associated with decreased micturation since one week and loose stools since one day,three episodes of loose stools on 5/01/2023( yesterday by 5:00pm ),decreased appetite since one week .
No history of nausea, vomiting ,cough, cold , breathlessness, chest pain ,loss of taste,neck rigidity, confusion ,giddiness ,joint pains ,burning micturation , exposure to toxins ,intoxication ,Diplopia,ear ache ,ear fullness ,trauma ,recent surgeries ,recent history of travel ,tremors
PAST HISTORY
Not a known case of HTN ,DM, TB, Asthma, thyroid abnormalities,psychiatric illness,epilepsy
Family history
Not similar complaints in family
Drug history
None
Surgical history
None
Personal history
80 year old female resident of adivivulapalli Nalgonda a house help by occupation mainly (washing utensils and clothes ) a mother of 11 children (5-sons ,6 -daughters alive among them are 2-sons and 4 -daughters ).
*Wakes up -7:00 am
*goes to work
*has breakfast at work (usually biscuits and tea)
* leaves to home by 1:30 pm
* prepared lunch and has lunch by 2-2:30pm
* spends her time washing dishes and clothes and cleaning the house till evening
* prepares dinner
*has dinner and goes to bed by 8:00 pm
DIET - mixed (consumes meat once a week )
- decreased since one week
BOWEL AND BLADDER -decreased frequency since one week and loose stools since one day (3 episodes of loose stools since one day )
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
Head to toe examination
Hair - normal
eyes-normal
ears-normal
no deviation of the mouth
Nails-no discoloration
chest: normal , no scars, sinuses , engorged veins
Abdomen:normal
spine: no deformity
VITALS
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
Head to toe examination:
Hair - normal
eyes-normal
ears-normal
no deviation of the mouth
Nails-no discoloration
chest: normal , no scars, sinuses , engorged veins
Abdomen:normal
spine: no deformity
SYSTEMIC EXAMINATION:
CNS EXAMINATION :
Higher mental functions:
On 5 th January
Speech : Comprehensive speech
Consciousness: Appears Lethargic
Behaviour : Co operative
Cranial nerve examination
1st nerve: olfactory normal
2nd optic nerve
Visual acuity: counting fingers
3rd 4th 6th nerve: oculomotor ,trochlear,abducens
Primary gaze present
EOM RT LT
SR normal
IR normal
SO normal
IO normal
Ptosis absent
Pupils reactive to light
5th nerve RT LT
Corneal reflex + +
Jaw jerk + +
Sensation over the face-present
7thh nerve;
Frowning absent
Orbicularis oculi
Nasolabial fold present
8th nerve
Vestibular cochlear
Rt left
Rinnies + +
Webbers + +
9th nerve
Uvula central
10th nerve
Gag reflex present
Hypoglossal nerve
Symmetrical tongue
Motor system
Muscle bulk -normal
Muscle tone -normal
Palpation
Power:
Grade 3 against gravity
Coordination movements normal
Finger nose test
Finger finger nose test
Involuntary movements Absent
Reflexes: Rt left
Corneal + +
Conjuctival + +
Palatial + +
Abdominal + +
Plantar + +
Deep Reflexes
Jaw jerk + +
Biceps reflex + +
Supinator reflex + +
Triceps reflex. + +
Knee jerk Could not ellicite
Sensory examination:
Fine touch crude touch present
responding to pain
Temperature felt
Vibration felt
No meningeal signs
No Cerebellar signs
CVS
On palpation
Apex beat was felt in the 5 th inter coastal space medial to the mid clavicular line
Jvp was normal
No precordial bulge
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
BLOOD GROUP -O (-ve )
APPT -36secs
PT -18 secs
BT -2 mins
CT -5 mins
INR -1.3
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*C
INJ OPTINEURON 1 ampule in 500 ml NS OD
MONITOR URINE INPUT AND OUTPUT
DISCUSSION:
Our main goal is to maintain the BLOOD PRESSURE hence the fluids RL is ideal for expanding the blood volume and maintains BP.
Tepid sponging is essential in bringing down the fever .
Since in sepsis (sinus tachycardia )persistent tachycardia the diastolic time decreased hence the supply to the myocardium decreases ,so the patients are prone for Ischemic damage to the heart
Due to the increased demand in hyperpyrexia a hyper metabolic state , supplementary oxygen should be supplied in order to prevent the ischemic damage to the heart
K+ can also be supplemented as potassium is borderline at 36
Hypokalemia can lead to paralytic ileus hence enteral nutrition should be avoided as it may lead to aspiration later .
Trace elements - Zn , selenium can be given in order to boost the immunity
Calcium should also be given since she is post menopausal elderly female ,probably with osteoporotic bones Ca-0.9
Nutrition plays an important role in recovery but since enteral nutrition is out of question parental nutrition can be given but lipid in tpn can again lead to problems
Common causes of fever in elderly woman include UTI And fungal infections
Hence urine culture should be send for
ABG should be done in order to rule out metabolic acidosis in this condition
Regular tlc counts should be checked for
To rule out DIC
serum ferritin
Serum lactate
Serum fibrinogen degradation products
INR AND PT should be done
Monitor for features of Shock
cold clumpy skin
Weak tready pulse
Sunken eyes
Hypotension
If further fall in BP occurs -NORAD is treatment of choice
Regular monitoring of glucose
A broad spectrum antibiotic in order to prevent infection since it’s a immune compromised state (NSAIDS and amino glucosides to be avoid since they are nephrotoxic and in our patient already urea and creatinine and high )
High risk for acute renal failure
Complications of sepsis
Sepsis induced encephalopathy
Acute renal failure
Respiratory failure for which she needs need ventilaton
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