C/O FEVER SINCE 2WEEKS

 Case History and Clinical Findings

C/O FEVER SINCE 2WEEKS

HISTORY OF PRESENT ILLNESS : PATIENT WAS APPARENTLY ASYMPTOMATIC 2 WEEKS BACK AND THEN SHE DEVELOPED FEVER 2 WEEKS A/W CHILLS AND RIGORS ANS RELIEVED IN BETWEEN BUT SINCE TODAY MORNING THE FEVER IS PRESENT ,HIGH GRADE ,CONTINOUS TYPE A/W CHILLS AND RIGORS ,HEADACHE +,NO AGGRAVATING AND RELIEVING FACTORS

NO H/O BURNING MICTURATION

NO H/O PAIN ABDOMEN , VOMMITINGS

NO H/O CHEST PAIN , PALPITATIONS

NO H/O COLD , COUGH

NO H/O PEDAL EDEMA,DRUG NON COMPLIANCE

HISTORY OF PAST ILLNESS :

K/C/O DM SINCE 9 YEARS AND ON INJ HAI/SC/TID 16U-16U-16U


INJ NPH SC /BD 14U-X-14U

K/C/O HTN SINCE 6 DAYS AND ON TAB TELMA 20MG PO/OD

N/K/C/O THYROID DISORDERS , ASTHMA , TB , EPILEPSY , CAD , CVA

MENSTRUAL HISTORY :

HYSTERECTOMY DONE 9 YEARS AGO

ON EXAMINATION

PT IS CONSCIOUS, COHERENT,COOPERATIVE

TEMP-101 F

PULSE RATE 92 BPM

BP 140/90 MMHG

GRBS -256MG/DL

CVS-S1 S2 HEARD NO MURMURS

RS- BAE PRESENT NVB

P/A-SOFT,NON TENDER


PROVISIONAL DIAGNOSIS:-

ENTERIC FEVER

DIABETES MELLITUS SINCE 9 YEARS

HYPERTENSION SINCE 1 WEEK

WITH ANEMIA-MCHC SECONDARY TO NUTRITIONAL CAUSE


Investigation

COMPLETE URINE EXAMINATION (CUE) 28-04-2024 05:16:PM:-

 COLOURPaleyellow

APPEARANCEClear

REACTIONAcidic

SP.GRAVITY1.010

ALBUMIN+++

SUGAR - Nil

BILE SALTS - Nil

BILE PIGMENTS - Nil

PUS CELLS - 4-5

EPITHELIAL CELLS - 2-4

RED BLOOD CELLS - Nil

CRYSTALS - Nil

CASTS - Nil

AMORPHOUS DEPOSITS - Absent

OTHERS - Nil

RFT 28-04-2024 05:16:PM :-

UREA - 21 mg/dl42-12 mg/dl

CREATININE - 0.9 mg/dl1.1-0.6 mg/dl

URIC ACID. -2.8 mmol/L6-2.6 mmol/L

CALCIUM - 10.0 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS - 2.0 mg/dl4.5-2.5 mg/dl

SODIUM -137 mmol/L145-136 mmol/L

POTASSIUM - 3.6 mmol/L.5.1-3.5 mmol/L.

CHLORIDE - 103 mmol/L98-107 mmol/L

POST LUNCH BLOOD SUGAR - 28-04-2024 05:19:PM:-237 mg/dl140-0 mg/dl

WIDAL TEST- 28- 04-202405:19:PM 

S.typhi 'O' Antibodies1:20S.

typhi 'H' Antibodies1:40S.

PARATYPHI 'AH' ANTIBODY

No Agglutinationseen

S.PARATYPHI 'BH' ANTIBODYNo Agglutinationseen


HEMOGRAM:-

28/4/24 -

HB-7.7

TLC-16000

PLT-4.07

RBC-4.05


29/4/24

HB-6.3

TLC-13200

PLT-2.77

RBC-3.39

30/4/24

HB-6.1

TLC-9700

PLT-2.99

RBC-3.25

DENGUE- NEGATIVE

MALARIAL PARASITE- NEGATIVE

M.P STRIP TEST- NEGATIVE

URINE FOR KB- NEGATIVE


Treatment Given:-

INJ AUGMENTIN 1.2GM IV/BD X 5 DAYS

INJ PAN 40MG IV/OD

INJ HAI S/C TID

INJ NPH S/C BD ACC TO GRBS

T.METFORMIN 500MG PO/OD

TAB TELMA 20MG PO/OD

T.DOLO 650MG PO/SOS

INJ IRON SUCROSE 200MG IN 100ML NS IV/OD

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