80 year old female with high grade fever

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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 
                     

 
                   
                     Slightly coated tongue 





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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