80 YEAR OLD FEMALE WITH PYREXIA
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S.SRIKAR
ROLL NO.144
CASE:
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
INVESTIGATIONS:
FEVER CHART:
LIVER FUNCTION TEST:
DENGUE ELISA:
DIAGNOSIS:
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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