49yr female with fever and decreased appetite

 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 box.



CHIEF COMPLAINTS 

 Fever since 15 days.

 Abdominal discomfort since 15 days.

Generalized weakness since 15 days.

Decreased appetite since 15 days.

Throat pain since 5 days.


HISTORY OF PRESENTING ILLNESS 

A 49 year female presented to the OPD with complaints of high grade Intermittent fever associated with chills, malaise and decreased appetite. Fever was relieved on taking medication. History of abdominal discomfort as tightness since 15 days not associated with vomiting. History of nausea associated with decreased appetite. No history of headache, retro orbital pain, cold, cough, chest pain, SOB, PND, Orthopnea, burning micturition.


she sought for consultation at local RMP and took medication (Antipyretic and Antibiotic), fever was releived upon taking medication associated with excessive sweating. She got fever spike on the same day, she sought for consultation at local hospital; she was treated with IV Antipyretic, Antibiotic and Analgesic medication daily on opd basis for 4 days. She stayed at home for the rest of 10 days and received treatment with Oral and IV Antipyretics, Antibiotics. Now admitted for further treatment and management.


PAST HISTORY 

Not a k/c/o DM,HTN, Tuberculosis, asthma

SURGICAL HISTORY

S/P - Tubectomy under LA in 1997.
S/P - Hysterectomy with B/L salpingo-oophorectomy under GA in 2014 i/v/o massive Uterine fibroid. 


PERSONAL HISTORY

Moderately built and nourished.
Sleep decreased.
Appetite lost.
Bowel and bladder are regular.
No addictions.


GENERAL EXAMINATION
Patient was conscious and coherent.
No pallor, Icterus, cyanosis clubbing,edema.
Cervical lymphadenopathy+
Neck rigidity.
Tonsillar enlargement with tonsilloliths and local pus.
Febrile

VITALS
PR: 92bpm; BP:110/80mmHg; RR: 22; SpO2: 98%@RA; Temp: 101°F; GRBS: 121mg/dl.
CVS: S1,S2+, No added sounds;
R/S: BAE+, Clear; 
P/A: Soft, Upper abdominal tenderness, BS+;
CNS: HMF intact; GCS 15/15; B/L Upper and lower limb time and power are normal; Kernig's and Brudzinski sign -ve.




FEVER CHART 




INVESTIGATION CHART

ECG 
                               
 
ENT cross consultation for further evaluation was done for enlarged tonsils and orders followed; throat swab was sent for Culture and sensitivity. Blood and urine culture were negative after 7 days of aerobic incubation which were sent on 17/08/2022. She was started on IV fluids, Cefriaxone antibiotic and other supportive management during the course in hospital. Her HB was 10.2, she was started on Oral Iron suppliments. 
On examination there was B/L tonsillar hypertrophy for which betadine gargles were given.

CHEST X-RAY  
                            

C-SPINE AP AND LATERAL VIEW 

                   


X-RAY KUB
                        

URINE CULTURE REPORT
                         

BLOOD CULTURE REPORT 
                        

HEMOGRAM
 

                     
 
ULTRASONOGRAPHY


2D ECHO was done on 19/08/2022 which showed e/o :
Mild TR; Trivial AR; No MR; No RWMA; No AS/MS; Sclerotic AV; Good LV Systolic function; Diastolic dysfunction; No PAH; IVC 0.7cms and collapsing; Minimal Pericardial effusion; RVSP 40mmHg.
Her fever spike was gradually subsided and general weakness improved.

PROVISIONAL DIAGNOSIS 
Typhoid fever with B/L tonsillar enlargement

TREATMENT 
1. IVF NS/RL @75ml/hr.
2. INJ. NEOMOL 100ml / IV / SOS ( IF TEMP >=102°F)
3. INJ. CEFTIAXOME 1gram /IV /BD.
5. TAB. DOLO 650mg/ PO / TID
6. Vital monitoring.

SOAP notes - 21/08/22
                                

S: Difficulty and pain during swallowing
No fever spike
Decreased weakness
Improvement in appetite

0:
Pt is conscious and coherent
PR:92
RR: 22
BP: 128/80mmHg
Temp: 98.6° F
GRBS:105 mg/dl
CVS: S1,S2+,No added sounds R/S: BAE +,clear
P/A: tenderness reduced
A: Typhoid Fever with B/L Tonsillar Enlargement(Rt>Lt)

P:

1. INJ. NEOMOL 1 gm /IV/SOS if
temp >102°F
2.ZOFER 4 mg /IV/TID
3. INJ.CEFTRIAXONE 1 gm / IV /BD.


Comments

  1. caregiver7careseekerNovember 16, 2022 at 10:29 PM

    Pratyusha the patient identifiers are visible in the qr codes. Please remove them asap and check and ask everyone else to remove those if they have uploaded the qr codes in error

    ReplyDelete

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