A case of 65 yr old female, Pyrexia under evaluation
February 22, 2022
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65yr Female Patient came to the casuality with c/o fever since 1week.
Patient was apparently asymptomatic 5yrs back .
Later diagnosed with HTN 5yrs back on visiting hospital for knee pain.
On medications tab.Telmisartan-40mg OD
Patient was diagnosed with DM 4yrs back on visiting hospital for regular check up
On medication tab .Metformin
Stopped medication since 6 months for the low sugar levels.
6 months back patient went to hospital for pedal edema since 1month and even complaints of foul smelling urine.
Patient was daignosed with CKD 6months back.
Now Patient came to the casuality with c/o fever since 1week.
High grade fever associated with chills and generalised weakness
O/E:
Pt is lethargic.
Febrile
Pr: 102bpm
Bp: 150/70mmhg
Spo2: 99@ RA
GRBS: 96mg/dl
RR: 14cpm.
RS: BAE+
CVS: S1 S2+
Cns: patient is lethargic
GCS: E3V1M6
Pupils: NSRL
Power: Moving all limbs.
Tone: normal
Reflexes B T S A K P
R: 2+ + + 2+ + plantar flexion
L: 2+ + + 2+ + flexion
Diagnosis: Pyrexia under evaluation.
Treatment :
1) Inj. Neomol 100 ml IV / TID
2)IVF - 0.9 % NS 75 ml / hr
3) Inj. PANTOP 40mg IV/ ID
4)Inj.Zofer 4gm IV / SOS
5)Inj.OPTINEURON 1 amp in 100ml NS/ IV/OD
6) Tab.ECOSPIRIN - AV ( 75 / 20) PO/HS
7) bp monitoring 2 nd hrly
8) GRBS monitoring 6th hrly
Investigations :
ECG-
AMC BED 5
SOAP notes day 1 :
Day 3 admission
65yr Female Patient
S: 2 fever spikes
O/E:
Pt is lethargic.
AFebrile
Pr: 110bpm
Bp: 170/100mmhg
Spo2: 99@ RA
GRBS: 93mg/dl
RR: 20cpm.
RS: BAE+
CVS: S1 S2+
Cns: patient is lethargic
Pupils: NSRL
Power: Moving all limbs.
Tone: normal
Reflexes B T S A K P
R: 2+ + + 2+ + plantar flexion
L: 2+ + + 2+ + flexion
A: Viral Pyrexia with anemia under evaluation, AKI on CKD k/c/o Dm and HTN.
P:
inj. Pan 40mg × iv od
Inj. Zofer 4mg iv od
Inj. Neomol 1gm iv sos
Tab. Dolo 650mg × po× Tid.
Tab. Telmisartan-40mg
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