65 yr old female came with complaint of fever with chills

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CHIEF COMPLAINT:

A 65 year old female patient who is a housewife came to the OPD  on 21.11.22 with the chief complaint of:

- fever associated with chills since 4 days.

-body pain since 3 days

-abdominal pain since morning of 21.11.22

-loose stools 4-5 times a day since morning 

-vomiting 1 episode 

HOPI:

The patient was apparently asymptomatic  5 days back then she developed fever associated with chills and rigors which is continuous in nature only relieved on medication, high grade, not associated with cold cough and burning micturition. The fever is associated with body pain and headache with no diurnal variation.

Since morning of 21.11.22, she felt abdominal discomfort accompanied with loose stools 4-5 times a day. She also had vomiting - 1 episode which were bilious i.e. without food particles and there is no complaint of nausea.

Daily Routine:

She wakes up at 8:00 am freshen up  and eat her breakfast of chapatti. She regularly takes her hypertension medication in the morning. She usually takes a nap between 10AM to 12pm. Then she do some household chores and eat lunch between 1:30-2:00pm. She takes rice for dinner and sleeps till 10pm.

PAST HISTORY:

K/C/O HYPERTENSION since 4 years on medication of Telma H.

N/K/C/O DM, TB, EPILEPSY, CAD, ASTHMA, THYROID.

PERSONAL HISTORY:

Married

Appetite: normal

Diet: mixed

Micturition: normal

Habits: no addictions , no pan chewing.

FAMILY HISTORY:

There is no similar complaints in her family.

GENERAL EXAMINATION:

The patient is examined in well light room. She is conscious, coherent and cooperative and well oriented to time, place and person and consent was taken to examine her.

Pallor- absent

Icterus- absent

Cyanosis- absent

Clubbing- absent

Lymphadenopathy- absent

Pedal edema- Absent

Malnutrition- absent

VITALS:

Temp- afebrile

PR-88bpm

BP-140/70mmHg

TPR SHEET:

                  

SYSTEMIC EXAMINATION:

CVS:

s1 and s2 sounds +

no thrills and no murmurs heard

RS:

Dyspnea: no

Wheeze: no

position of trachea: central

vesicular breath sounds heard

Abdomen:

shape of abdomen: scaphoid

soft and non tender 

 no organomegaly detected

CNS:

conscious

normal speech 

cranial nerves are intact

sensory system normal 

motor system normal

Gait- normal

REFLEXES: BICEPS  TRICEPS  SUPINATOR  KNEE        ANKLE

RIGHT           2+            2+             2+                  2+               2+

LEFT            2+             2+            2+                   2+               2+

Cerebellar signs:

-finger -nose -in- coordination: absent

-knee-heel-in-coordination: absent

INVESTIGATIONS:

USG: 

USG IMPRESSION: ACUTE CHOLECYSTITIS, GRADE2 FATTY LIVER AND BILATERAL INCREASED ECHOGENICITY IN KIDNEYS.

ECG:

2D ECHO:

ELECTROLYTES AND HEMOGRAM:

Chest X Ray :

PROVISIONAL DIAGNOSIS:

-Viral pyrexia with thrombocytopenia

-NS1 antigen positive- Dengue positive 

TREATMENT PLAN:

1.IVF NS @100ML/HE

2.TAB DOLO 650MG PO/SOS

3.TAB SPOROLAC-DS 120MG PO/TID

4.BP MONITORING 4TH HOURLY

5.VITALS MONITORING 6TH HOURLY

6.TEMPERATURE MONITORING 4TH HOURLY

7.INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD OVER 30 MINS

8.INJ NEOMOL 1GM IV/SOS IF TEMO >101F