A 70 year old female patient with FEVER and chills
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Pabba.Navyasri
Roll no 111 70 year old female patient came to Medicine department with chief complaints of Fever with chills since 7 days.
Pallor - Present
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 ;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 but this is 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.
Icterus - Absent
Cyanosis -Absent
Clubbing -Absent
Kolinychia -Absent
Generalised Lymphadenopathy -Absent
Bilateral Pedal Edema -Absent
Perfollicular rash- petechiae
VITALS
PR: 89bpm
BP:120/80 mmhg
RR:16cpm
Temp:99F
SpO2 :98%
GRBS :234mg%
13/10
BP: Supine-120/70
Standing- 110/60
SYSTEMIC EXAMINATION:
CNS EXAMINATION
1. HIGHER MENTAL FUNCTIONS:
a. Conscious
b. Well Orientation to time, place and person
c. Speech and language – normal
d. Memory – immediate-retention and recall, recent and remote are present
e. No delusions, hallucinations
f. No Emotional lability
2.CRANIAL NERVE - Right left
Normal Normal
3.MOTOR SYSTEM-
Bulk
Inspection Normal Normal
Palpation Normal Normal
Measurement
Upper limb – 10cm below acromion ( same on both )
Lower limb 18 cm below tibial tubercle (same on both)
Tone
Upperlimb Normal Normal
Lowerlimb Normal Normal
Power
a. Neck muscles Good Good
b. Upper limbs
i) Shoulder 5/5 5/5
Flexion-Extension
Lateral Rotation-Medial Rotation 5/5 5/5
Abduction -Adduction 5/5 5/5
ii) Elbow
Flexion-Extension 5/5 5/5
iii) Wrist
Dorsi flexion-Palmar flexion 5/5 5/5
Abduction-Adduction 5/5 5/5
Pronation-Supination 5/5 5/5
iv) small muscles of hand Good Good
v) Hand grip Good Good
c. Lower limbs
i) Hip 5/5 5/5
Flexion-Extension
Abduction-Adduction 5/5 5/5
Lateral Rotation-Medial Rotation 5/5 5/5
ii) Knee
Flexion-Extension 5/5 5/5
iii) Ankle
Dorsi flexion-Plantar flexion 5/5 5/5
Inversion-Eversion 5/5 5/5
iv) Small muscles of foot Good Good
REFLEXES
SUPERFICIAL REFLEXES
A.Corneal reflex Present Present
B.Conjunctival reflex Present Present
C.Abdominal reflex Present Present
D.Plantar reflex Present Present
DEEP REFLEXES
A.Biceps +2 +2
B.Triceps +2 +2
C.Supinator +2 +2
D.Knee jerk +2 +2
E.Ankle jerk +2 +2
SENSORY SYSTEM Normal Normal
CEREBELLAR SIGNS Absent Absent
SIGNS OF MENINGEAL IRRITATION Absent
1.Plantar reflex of left leg
2.Plantar reflex of right leg
3.Ankle jerk of left leg
4.Ankle jerk of right leg
5.knee jerk of left leg
6.knee jerk of right leg
7.Biceps reflex
8.Supinator reflex
9.Triceps reflex of left arm
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
RESPIRATORY SYSTEM EXAMINATION :
-Shape of the chest -normal,
-Trachea appears to be in centre
-Normal vesicular breath sounds heard
CARDIOVASCULAR SYSTEM EXAMINATION
- S1 S2 heard
- No murmurs
ABDOMEN EXAMINATION
- Shape of the abdomen -slightly distended
- No tenderness
- No local rise of temperature
- Nopalpable masses
- liver and spleen are not palpable
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
12/10
HbA1c - 6.8%
FBS -139mg/dl
Hb - 11.9
TLC -2,800
RBC -3.86
Urea -20
Creatinine- 0.8
Platelets -32000
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
-T Ultracet
On 13-10
IVF NS , RL 150ml/hr
- inj. NEOMAL 1gm
-DOLO 600mg per oral
-Tab.GLIMIPERIDE 1mg per oral OD
- Tab. METFORMIN 500mg per oral OD
-T Ultracet
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