49F pyrexia under evaluation, UTI with anemia of chronic disease. K/c/o HTN since 15years
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A 49 year old female HouseMaker by ouccupation presented to the Casualty with
CHEIF COMPLAINTS:
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 15 days back, then she developed Fever which was high grade, associated with chills and rigors, No aggrevating factors, and relieved on taking medication. Dysphagia since 5 day, which is more to solids than liquids and is associated with pain.
H/O loose stools since 5days,Initially 6 episodes/days and since 2 days(2-3 episodes/day).Stools were watery and non blood stained.
H/O SOB (Grade II-III) since 2days, No Orthopnea, No PND.
HISTORY OF PAST ILLNESS:
She is K/C/O DM since 1 year (not on medication) and HTN since 11 yrs (On medication)
She is also a K/C/O Hypothyroidism since 7 years On Thyronorm 50mcg and K/C/O Pulmonary miliary TB and Rheumatoid Arthritis (not on medication).
She is N/K/C/O ASTHMA EPILEPSY CVA CAD.
PERSONAL HISTORY:
Appetite - Decreased since 5 days.
Sleep - Inadequate.
Diet - Mixed (consumes both veg & non veg)
Allergies- to chicken since 8-10yrs (H/O loose stools for a day after eating chicken)
Micturition- 7-8 times in a day not associated with burning sensation.
Bowel and Bladder movements-Regular.
No addictions
ROUTINE HISTORY:
Patient wakes up at 6:30 am and does some of her household chores and then rests on the bed while watching television. She has her breakfast by 8 am and does some small walks in the house frequently, then she has her lunch around 2 pm and sleeps in the afternoon and wakes up around 6pm. She drinks Tea and does the remaining household chores and has her dinner by 9 pm and sleeps by 10 pm.
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative and well oriented to time, place and person
Pallor mildy present.
No Icterus/cyanosis/clubbing/lymphadenopathy.
VITALS:
BP - 140/80 mmHg
PR- 86 bpm
RR- 18 cpm
Temp - 102F
CVS - S1 S2 heard , no murmurs
RS - BAE+, no added sounds
P/A - soft and non tender
CNS - NFND
INVESTIGATIONS:
SEQUENCE OF EVENTS:
PROVISIONAL DIAGNOSIS:
PYREXIA UNDER EVALUATION WITH ? UTI WITH ANEMIA OF CHRONIC DISEASE
HTN + SINCE 15 YEARS
HYPOTHYROIDISM SINCE 10 YEARS, PULMONARY KOCH’S 6 YEARS AGO
AKI ON CKD SINCE 2 YEARS WITH GLOSSITIS WITH ORAL CANDIDIASIS WITH LEFT OTOMYCOSIS WITH ? STEVEN JOHNSON’S SYNDROME.
TREATMENT:
1.INJ. NEOMOL 1gm IV/SOS
2.Tab. PCM 650mg PO/TID
3.INJ. LASIX 40mg IV/BD
4.T.THYRONORM 50mcg PO/OD
5.T.AMLONG 5mg PO/OD
6.ZYTEE GEL L/A
7.CADIBIOTIC EAR DROPS
8..2% BETADINE GARGLE 5ml diluted in 1/2 glass water 3-4 times /day
9.KENOCORT ORAL PASTE
10.NEOSPORIN-H OINTMENT L/A
11.CANDID MOUTH PAINT L/A BD
12.VENSULA MAX LOTION FOR L/A BD
13.NS COMPRESSOR TID
14.VITALS MONITORING
15.I/O CHARTING
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