A 77 year old male with fever, cough and abdominal discomfort

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DR JATIN SHARMA 

Roll no. 56

77 YR OLD MALE WITH FEVER, COUGH AND ABDOMINAL DISCOMFORT 

 

Date of admission 20-12-22 

C/o fever associated with chills & rigours since 6-7days 

C/o Seizures, 1 episode-3days ago 

C/o cough with Sputum since 2-3 days

C/o abdominal discomfort since 2-3 days

HOPI :

Patient was apparently asymptomatic 6-7days back, then he developed fever of mild to moderate grade, which was insidious in onset, gradually progressive in nature associated with chills, cold, cough with sputum which relieved on medication. Then he had an episode of seizures 4days ago where all 4 limbs were stiff, up rolling of eyes were present, frothing from mouth and passed urine during the seizure episode. He also developed bloating and abdominal discomfort. 

PAST HISTORY:

Patient is a known case of DM since 1 year and he is on medication.

Not a known case of HTN, Asthma,epilepsy,tuberculosis and thyroid abnormalities.

PERSONAL HISTORY:

Sleep: adequate 

Appetite: decreased

Diet: mixed

Bowel and bladder movements: 

Addictions: none 

FAMILY HISTORY:

No similar complaints in the family

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative, moderately built and moderately nourished.

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy: absent

Pedal edema: absent

VITALS:

Temperature: Afebrile 

Pulse: 82 beats/minute

Blood pressure:110/70mm Hg

Respiratory rate: 18 cpm

SYSTEMIC EXAMINATION:

CVS: S1 and S2 are heard

RS- Bilateral air entry present 

B/l infra axillary area and infra scapular area crepts present  

CNS: E4V5M6, higher mental functions intact

P/A- soft ; non tender bowel sounds present, mild splenomegaly present  

CLINICAL IMAGES :-

                                                        

INVESTIGATIONS:

                                           

                  ECG DONE ON 20-12-22  

                 ECG DONE ON 24-12-22

                 2D ECHO DONE ON 21-12-22

                                           

    USG abdomen and pelvis done on 20-12-22

        20-12-22 chest xray PA view 

                                           

           21-12-22 chest xray lateral view 

               23-12-22 chest x ray PA view 

                  Fever chart 

         Hemogram from 22-12-22 to 25-12-22

PROVISIONAL DIAGNOSIS 

pyrexia under evaluation secondary to ? Clinical malaria with renal AKI on ? CKD  with panctopenia secondary to ? hypoprolifrative marrow ? inflammation ?chronic disease with h/o seizures 1 episode 3 days ago secondary to hypoglycemia? with hyponatremia(resolved) with k/c/o type 2 DM since 2 years with acute liver injury 

TREATMENT (updated) 

* Tab doxycycline 100mg PO BD

* IV fluids NS at 100ml/hr

* T. Pantop d po/od 

* Inj. zofer 4mg iv BD

* Inj. Human Act rapid insulin sc. TID

* T. Levipil 500mg po BD

* T. Dolo 650 mg PO BDI 

* Inj. Neomol 1mg iv if temperature is more than 101F

* Vital monitoring   4th hourly 

* GRBS  6 th hourly 

* SYP.  creamaffin 15ml/PO/HS 

* T. Riboflavin 5mg po BD

* oral mucopan gel for L/a

* Neb. Salbutomol 1resp. P/N TID

* plenty of oral fluids