A 70 year old female patient with FEVER and chills

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 patient's 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 the comment 

Pabba.Navyasri 

Roll no 111



 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 ;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.

  Pallor                       - Present 
  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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