55 year old female came to opd with c/o high grade fever
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PATIENT CAME TO OPD WITH
C/O FEVER SINCE 1 MONTH
C/O SOB GRADE 2/3 SINCE 10 DAYS
COUGH SINCE 10 DAYS
HISTORY OF PRESENT ILLNESS
PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK THEN SHE DEVELOPED FEVER - INITIALLY LOW GRADE FOLLOWED BY HIGH GRADE FEVER, FEVER WITH CHILLS AND RIGORS, ASSOCIATED WITH LOSS OF APPETITE,NOT ASSOCIATED WITH LOOSE STOOLS , NO NAUSEA, VOMITING.
ADMITTED OUTSIDE AND TREATED , PATIENT TOLD THAT HER PLATELET COUNT WAS LOW WHICH EVENTUALLY CAME TO NORMAL
SINCE 10 DAYS AGAIN PATIENT HAD FEVER, HIGH GRADE ASSOCIATED WITH SOB, DRY COUGH
H/O LOOSE STOOLS 4-5 DAYS BACK, SUBSIDED AFTER MEDCATIONS
NO BURNING MICTURITION
N/K/C/O DM,HTN
VITALS
TEMP: 103 F
PR : 98
BP : 170/100 MMHG
RR : 22 CPM
SpO2 : 88 % @ RA 99% with 6L O2
GENERAL EXAMINATION
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPADEMOPATHY
MILD PEDAL EDEMA
SYSTEMIC EXAMINATION
CVS : S1S2 +
RS : B/L DIFFUSE WHEEZE +
B/L COAUSE CREPETATIONS + (R>L)
P/A : NON TENDER
LIVER : NON PALPABLE
SPLEEN : PALPABLE
INVESTIGATIONS
OUTSIDE REPORTS
12/11/21
HB: 11.8
TLC: 3,500
PLT: 1,37,000
13/11/21
HB: 11.1
TLC: 3,200
PLT: 1,11,000
14/11/21
HB: 11.5
TLC: 3,600
PLT: 1,33,000
DENGUE WAS NEGATIVE ON 13/11/21
REPORTS FROM KIMS FROM 26/11/21
ABG
pH : 7.51
PcO2 : 29.3
Po2 : 63.7
HCO3 : 23.3
HB : 8.8
TLC : 8.8
PLT : 1.1 LAKHS
CUE : ALBUMIN +
RBS : 113
Na+ : 136
K+ : 3.7
Cl- : 94
UREA : 22
CREATININE : 0.7
TOTAL BILE : 1.01
DIRECT BILE : 0.42
SGOT : 94
SGPT : 55
ALP : 334
TOTAL PRIME : 62
ALBUMIN: 2.4
USG ABDOMEN : SPLENOMEGALY
MALARIA STRIP TEST : NEGATIVE
INVESTIGATIONS ON 27/11/21
HB : 9.8
TLC : 5,100
PLT : 1.05 L
2D ECHO :
USG
DIFFERENTIALS DIAGNOSIS :
CLINICAL MALARIA
VIRAL PNEUMONIA
TREATMENT
1) IVF NS , RL @ 75 ml/hr
2)INJ.OPTINEURON 1 AMP IN 100 ml NS IV
3)INJ.PAN 40 mg IV /OD
4)INJ.CEFTRIAXONE 1g/IV/BD
5)INJ FALCIGO 120 mg/IV
6)INJ.ZOFER 4mg IV/SOS
7)T.PCM 650mg PO/QID
8)INJ.NEOMAL 1g/IV/SOS if temp >101F
