70 year old female with fever and chills

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Rakshitha Reddy 

Roll no 106

 70 year old female patient came to Medicine department with chief complaints of Fever with chills since 7 days.

HISTORY OF PRESENTING ILLNESS:

-H/O an episode of vomiting on 7/10/22  contained food particles 

-H/O headache since 1 yr on Right Side and middle of scalp ;relieved on applying oil or balm after about 3 hours.

But since 10 days Headache is severe and is not being relieved with oil or balm.

-H/O burning sensation over dorsum of foot and legs since 5 years which was more since 10 days.

-H/O arm swelling since 10 days.

PAST HISTORY:

She is a known case of

- Diabetes since 15 years(metformin and glimi 1;  Presently-glimi2)

 -Hypertension since 3 years(losartan and hydrochlorthiazide)

 -Underwent right eye operation 1 year back

 -Piles since 10 months 

PERSONAL HISTORY:

-She wakes up at around 6:00am goes  for 1 hour walk and 

-has milk or Java and

-in afternoon around 12 pm she eats rice with some vegetable curry (she takes only veg diet)

-and around 8 pm She eats Gatka 

-Appetite decreased 

-Sleeps only 3 to 4 hours

-Bladder - normal

-Bowel    -She takes syrup every night then next day    morning she passes faeces. If she tries hard to pass   faeces without having syrup ; then she bleeds per  rectum.

-No addictions 

FAMILY HISTORY:

Her father ;uncle;2 brothers are diabetics.

GENERAL PHYSICAL EXAMINATION:

Patient is Conscious ;Coherent and Cooperative  

And Well oriented to Time ;Place and Person.

  Pallor                       - Present 

  Icterus                     - Absent

  Cyanosis                  -Absent

  Clubbing                   -Absent

  Kolinychia                 -Absent

  Generalised Lymphadenopathy -Absent

  Bilateral Pedal Edema -Absent

VITALS

PR:  89bpm

BP:120/80 mmhg

RR:16cpm

Temp:99F

SpO2 :98%

GRBS :234mg%

ANKLE JERK

 https://youtube.com/shorts/qUDuDmvxO2Q?feature=share

GAIT

https://youtube.com/shorts/kjTQX1ea0WA?feature=share

KNEE JERK

https://youtube.com/shorts/4VS6Ekc2fuA?feature=share

ROMBERGS SIGN

https://youtube.com/shorts/FcV2nvlMQBg?feature=share

INVESTIGATIONS:

 

On 11/10

Hb-11.9

TLC-4,400

Platelets-22000

Blood urea- 35

Serum creatinine-1.2

Serum sodium    - 132

Serum potassium-3.7

Serum chloride     -96

S.Calcium             -0.89

PROVISIONAL DIAGNOSIS:

 Viral Pyrexia with Thrombocytopenia 

TREATMENT:

on 11-10

- IVF NS , RL 150ml/hr

- inj. NEOMAL 1gm 

-DOLO600mg per oral

-Tab.GLIMIPERIDE  per oral OD

- Tab. METFORMIN 500mg per oral OD

On 12-10

- IVF NS , RL 150ml/hr

- inj. NEOMAL 1gm 

-DOLO 600mg per oral

-Tab.GLIMIPERIDE 1mg per oral OD

- Tab. METFORMIN 500mg per oral OD