62 year old with fever

 

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 

SHIVANI DANDU.

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 tap done on 15/11/22.
 
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.

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