62 year old with fever
62 year old with fever
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A 62 year old female, labourer ( in farms ) by occupation presented to the OPD with chief complaints of fever and cough since 10 days .
History of presenting illness : The patient was apparently asymptomatic 10 days back , then she developed high grade fever associated with chills and rigors , continuous in nature with no diurnal variation , only relieving with medications . The fever is associated with generalised weakness and body pains .
She also has dry cough that is causing SOB even on sitting or lying down .
She has visited the local doctor for 2 days (was given saline) before coming to our OPD .
Past history : The patient is not a known case of DM, HTN, asthma, epilepsy, thyroid disorders, CAD, TB .
Personal history : The patient works as a labourer in cotton fields from 8 am to 6 pm 10 days back , but now as she is not well she is not going for work .
Diet - mixed
Appetite - decreased
Sleep - inadequate
Bowel and bladder movements - regular
Addictions - consumption of betel leaves 3 times/day since 30 years .
General Examination : The patient is conscious, coherent and cooperative, well built and nourished .
Pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy and pedal edema are absent.
VITALS :
Temperature - 99 F
BP - 120/80 mm Hg
HR - 83 bpm
RR - 16 cpm..
Systemic Examination :
CVS :
On palpation ‐
• Apex beat was felt in the left 5th intercostal space medial to the mid clavicular line.
• JVP was normal
• No precordial bulge
• No parasternal heave
On auscultation ‐ S1, S2 heard , no murmurs
RS :
On inspection ‐
• Chest is bilaterally symmetrical
• Expansion of chest: Equal on both sides
• Position of trachea: Central
• No visible scars, sinuses, pulsations
On palpation :
• Expansion of chest was equal on both sides.
• Position of trachea: Central
• Tactile Vocal Fremitus: resonant note was felt.
On percussion: all lung areas were resonant
On auscultation :
• Bilateral air entry was present, Inspiratory crepts present in B/l infraaxillary and infra scapular areas
• Vocal resonance: resonant in all areas
P/A : soft, non tender, no organomegaly, no distension, bowel sounds heard.
CNS : The patient is well oriented to time, place, person.
Higher mental functions are intact.
Cranial nerve examination :‐
All cranial nerves are intact and functioning.
Motor System Examination :‐
• Normal bulk in upper and lower limbs
• Normal tone in upper and lower limbs
• Normal power in upper and lower limbs
• Gait is normal .
. Reflexes are normal .
Sensory System Examination :‐
Normal sensations are felt in all the dermatomes.
No cerebellar signs .
No meningeal signs.
Fever chart
Investigations :
Hemogram
LFT
RFT
ECG
USG of abdomen
2D echo
Pleural fluid analysis
LDH:569
SUGAR:117
PROTEIN:2.5
VOLUME:1.5 ml
COLOUR: yellow
TC:18,150
DC:98% Neutrophils,2% lymphocytes, occasional mesothelial cells seen.
MRI REPORT
Provisional Diagnosis : Pyrexia under evaluation (?COMMUNITY ACQUIRED PNEUMONIA)..
Treatment :
1) IV fluids - 50ml/hr
2) Inj. Neomol 1 gm IV SOS if temperature>101F
3) Tab. Amoxicillin - 625 mg PO TID
4) Syrup Ascoryl 10 ml TID
5) Tab. Pantop 40 mg PO OD
6) Tab. Dolo - 650 mg PO TID..
13/11/22
IVF (2 NS,1 RL)
INJ OPTI NEURON 1 AMP IN 100 ML NS OVER 1 HR
INJ MAGNEX FORTE 1.5 GM/IV/BD
INJ NEOMOL 1 GM IV/SOS
TAB DOLO 650 MG PO/TID
SYP.ASCORYL 10 ML /PO/TID
TAB PAN 40 MG PO/OD
MONITOR TEMP/ BP 4 TH HRLY
14/11/22
IVF( 2 NS,2 RL@ 100 ML/ HR)
INJ..MAGNEX FORTE 1.5 GM/IV/BD
INJ NEOMOL 1 GM IV/SOS
TAB DOLO 650 MG PO/TID
SYP.ASCORYL 10 ML /PO/TID
TAB PAN 40 MG PO/OD
MONITOR TEMP/ BP 4 TH HRLY
15/11/22
IVF( 2 NS,1 RL@ 100 ML/ HR)
INJ..MAGNEX FORTE 1.5 GM/IV/BD
INJ NEOMOL 1 GM IV/SOS.
TAB DOLO 650 MG PO/TID
SYP.ASCORYL 10 ML /PO/TID
TAB PAN 40 MG PO/OD
TAB AZITHROMYCIN 500 MG PO/OD
MONITOR TEMP/ BP 4 TH HRLY
.
16/11/22
1.IVF( 1 NS,1 RL@ 100 ML/ HR)
2.INJ.MAGNEX FORTE 1.5 GM IV/BD
3.INJ OPTINEURON 1 AMP IN 100 ML NS OVER 1 HOUR
4.INJ NEOMOL 1 GMIV/ SOS
5.INJ LASIX 20 MG.
