80 YEAR OLD FEMALE WITH PYREXIA

 80 years old female resident of Nalgonda,Home maker by occupation,presented to OPD with complaints of FEVER since 1week.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 7 days ago later which she developed high grade fever intermittent type associated with chills with no aggrevating factors and relieved on taking medication,generalised weakness since 2 days.

No history of any vomitings,cough,shortness of breath, cold,stomach pain.

PAST HISTORY:

No history of Hypertension,Diabetes mellitus, Asthma, Epilepsy, Tuberculosis,Coronary Artery disease.

PERSONAL HISTORY:

Diet: Mixed(eats meat once in a week)

Appetite: decreased 

Sleep: adequate

Bowel and bladder movements: normal

No addictions

No allergy


TREATMENT HISTORY:

No significant treatment history

FAMILY HISTORY:

No significant family history

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative well oriented to time, place and person. Moderately built and nourished.

Pallor-Present

Icterus-Absent

Cyanosis-Absent

Clubbing-Absent

Lymphadenopathy-Absent

Edema-Absent

VITAL SIGNS:

Temperature-104°F

Blood Pressure-110/70 mm Hg 

Pulse Rate-130 bpm

Respiratory rate-16cpm



SYSTEMIC EXAMINATION:

CVS EXAMINATION:

S1,S2 heard, no murmurs

RESPIRATORY EXAMINATION:

       trachea is central in position

       Normal vesicular breath sounds heard

       BAE +

ABDOMEN EXAMINATION:

soft,non tender,no organomegaly

CNS EXAMINATION:

No focal neurological deficits

PROVISIONAL DIAGNOSIS:

Fever under evaluation

FEVER CHART:



INVESTIGATIONS:










ECG:

Sinus tachycardia-due to hyperpyrexia

CHEST X-RAY:-


HAEMOGRAM ON 5/1/2023:-
HB:-9.5g/dl
TLC:- 7600cells/cu.mm
NEUTROPHILS:-90%
LYMPHOCYTES:-7%
EOSINOPHILS:-0
MONOCYTES:-3%
BASOPHILS:-0
PCV:-29.0vol%
MCV:-87.6
MCHC:-32.8
MCH:-28.7
RBC:-3.31millions/cu.mm
PLATELET COUNT:-80,000/cu.mm

HAEMOGRAM ON 6/1/2023:-
HB:-9.3g/dl
TLC:- 7000cells/cu.mm
NEUTROPHILS:-92%
LYMPHOCYTES:-6%
EOSINOPHILS:-0
MONOCYTES:-2%
BASOPHILS:-0
PCV:-29.0vol%
MCV:-88.4
MCHC:-32.1
MCH:-28.4
RBC:-3.28millions/cu.mm
PLATELET COUNT:-1 Lakh/cu.mm

DIAGNOSIS:

VIRAL PYREXIA with THROMBOCYTOPENIA
HYPOVOLEMIC SHOCK 2° TO SEPSIS

TREATMENT:

1.IV FLUIDS-RINGER LACTATE @100ml/hr

                      NORMAL SALINE @100ml/hr

2.INJ.NEOMOL

3.TAB.DOLO 650mg                              

4.INJ.OPTINEURON 



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