65F lowbackache, fever, shortness of breath 2 weeks

 

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65years old female housemaker by occupation presented to casualty with 

CHEIF COMPLAINTS:

Pain in right lower limb since 1 week.

Fever since 1 week

Shortness of breath since 1 week

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 week back, then she developed pain in right lower limb and right side of lower back- insidious in onset and gradually progressing.

No history of trauma, injury 

Fever- low grade, intermittent and associated with chills and rigor, relieved by medication

Shortness of breath- Grade II

C/o decreased urine output since 1 year

No c/o pedal edema, facial puffiness

C/o constipation- passes stools every 2-3 days

C/o decreased appetite since 1 week

No c/o pain abdomen, burning micturition, chest pain, palpitations

PAST HISTORY:

She is a Known case of hypertension since 10 years, on regular medication TAB. AMLO -AT 5/50 OD

Not a known case of DM, TB, Epilepsy, CVA, CAD, Thyroid disorders, Bronchial asthma.

PERSONAL HISTORY:

1.Diet-mixed (consumes both veg and non veg)

2.Appetite: decreased since 1 week

3.Bladder movements - decreased since 1 year

4.Bowel: constipation, passes stools for every 2-3 days

5. Sleep -adequate

6.Addictions-nil

ROUTINE HISTORY:

she wakes up at 7am and as tea and starts doing her daily chores, meanwhile she eats her breakfast at around 8am and watches tv. Then she has lunch by 1pm and takes rest till 4pm.Has tea at 5pm and starts dinner preparation at 6pm and has her dinner at 8 pm and goes to sleep 9 pm.

GENERAL EXAMINATION:

The patient was examined in a well-lit room after informed consent was taken.

She is conscious, coherent, cooperative, well oriented to time, place and person, well nourished and moderately built.

No pallor, Icterus, Clubbing, Cyanosis, Koilonychia, Lymphadenopathy, Edema.

VITALS:

1. Temp: 99.1 F
2. BP: 120/70mm Hg
3. PR: 78bpm
4. RR: 18cpm
5. Spo2: 96% on RA
6. GRBS : 87mg/dl

SYSTEMIC EXAMINATION:

RS: BAE present, Normal vesicular breath sounds heard

CVS: S1, S2 heard

CNS: No focal neurological deficit

PER ABDOMEN: soft, non tender

INVESTIGATIONS:

29/7/2023

CBP:

Hb:  12.7 gm/dl

TLC:   14100 cells/ cumm

RBC:   4.78 million/cumm

PLT:   4.50 lakh/cumm

PCV: 39.6  vol%

Neutrophils:71 %

Lymphocytes:21 %

Eosinophils: 2%

Monocytes: 6%

MCV: 82.8 fl

MCH:26.6 pg

Peripheral Smear: Normocytic normochromic blood picture with leucocytosis

RFT:

Blood urea:  37 mg/dl

Serum creatinine: 0.8 mg/dl

Serum electrolytes: 

Na+:   142 mEq/l

K+:  4.5 mEq/l

Chloride :  99 mEq/l

LFT:

Total bilurubin:0.68mg/dl

Direct bilurubin :0.20 mg/dl

AST:33 IU/L

ALT:43 IU/L

Alk phosphatase:249 IU/L

Total Protien:6.4 gm/dl

Albumin:3.0 gm/dl

A/G ratio: 0.89

CUE:

Albumin:nil

Sugars:nil

Pus cells:2-3/HPF

Epithelial cells:2-3/HPF

RBS: 76mg/dl

Serology: NEGATIVE

USG ABDOMEN AND PELVIS: Impression

1. Right grade I RPD changes.

2. Raised echogenicity of left kidney 

USG CHEST: Impression

B/L mild pleural effusion 

2D ECHO:

Trivial TR+, No MR/AR

No RWMA, No AS/MS, Sclerotic AV

Good IV systolic function

Diastolic dysfunction +, No PAH/PE.

Chest X-ray:

Xray LS spine:decreased L5 disc space.

Xray B/L knees: Grade IV osteoarthritis knee.

MRI LS spine and whole spince screening : Impression-

1. L3-L4 infective spondylodiscitis

2. L3-L4 disc protrusion causing sever canal stenosis

3. Thin rim of prevertebral collection at L3-L4 level

4. 30x14mm and 20x11mm collection in right psoas muscle.

5. Small bilobed epidural collections behind L3-L4 vertebral bodies

PROVISIONAL DIAGNOSIS:

Pyrexia under evaluation with mild B/L pleural effusion.

TREATMENT:

1. INJ. NEOMOL 1gm IV/SOS ( if temperature >101F)

2. INJ. OPTINEURON 1amp in 100 ml NS IV/OD

3. INJ. MONOCEF 1gm IV/BD 

4. TAB. PCM 650mg PO/BD

5. TAB. AMLONG -AT 5/50 PO/OD

6. INJ. TRAMADOL 1amp in 100ml NS IV/BD

Orthopaedic management of the case:

1. Inj. TRAMADOL 1amp in 100ml NS IV/BD

2. TAB GABAPENTIN 100mg H/S x 15days

3. TAB. EVION LC BD x 15days

4. TAB. MYORIL 4mg BD x 3days

Advised for L3-L4 vertebral body biopsy and L2- L5 Posterior screw fixation.