72 Female with Fever, Burning micturition, Abdominal pain

 Chief complaints: 

Fever since 1month (sep15th)

Burning micturition for 10days (sep15th -25th)

Abdominal pain since 1month 

Decreased appetite since 20 days

HISTORY OF PRESENTING ILLNESS:

A 72 year post menopausal female , came to casualty with complaints of fever since sep15th ( 36th day of illness). Fever was high grade with evening rise in temperature associated with chills and rigors, not associated with nausea and vomiting/headache/cold/cough . She was treated with oral medicines on day 2 of illness,But fever dint subside . Not associated with loose stools /blood in stools

On 2nd October (17th day of illness ) she was given IV antibiotics for 2 days , and was on antipyretics

From 9th October she had feverspike , she consulted a doctor, she was started on inj. Magnexforte and Tab. Farepeneum 200mg for a week. 

 “presented to outside hospital with fever , right hypochondriac pain and nausea , she was clinically as SEPSIS WITH MODS, surgical opinion was taken and adviced for lap cholecystectomy for acalculous cholecystitis, but they refused.,  advised to get CECT abdomen but she got chills after a test dose of contrast. The physician thought of melioidosis and started on Meropenem .Blood and urine cultures were not done”

As told by the doctor 

On 19/10/22, they are referred to our hospital 

PAST HISTORY:

K/c/o Hypertension since 20yrs and was on Amlodipine 5mg + atenolol 50mg 

K/c/o Type 2 diabetes mellitus since 22 yrs and is on Tab. Glimepiride 2mg+Tab. Met Formin 500mg

Surgery: Right PFN 11yrs ago

PERSONAL HISTORY:

Decreased appetite takes mixed diet, irregular bowels( Type 1 Bristol stool) ,normal micturition , no allergies 

Family history: not significant 

 MENSTRUAL HISTORY: 

Age of menarche - 15yrs

LMP- post menopausal status

OBSTETRIC HISTORY:

Age at marriage-12yrs

Gravida 3 (all 3 are Full term NVD)

1st male , 2nd female - died

3rd - female alive 

GENERAL PHYSICAL EXAMINATION 

Patient conscious coherent cooperative 

Moderately built and nourished

No, icterus, cyanosis, clubbing, lymphadenopathy 

Pedal edema upto lower end of tibia 

 Vitals

Bp:160/90mmhg

RR-

PR-98bpm

SPO2-94%

GRBS-343mg/dl (inj. HAI 12 units given)

TEMP-98.3F

Pallor present 

Chest x ray PA view

 SYSTEMIC EXAMINATION:

CVS:  S1 S 2Heard

RS: SOB GRADE 2 MMRC, vesicular breath sounds

PER ABDOMEN: scaphoid, nontender, BS +

CNS: NFND

DIAGNOSIS:

PYREXIA OF UNKNOWN ORIGIN

TREATMENT:

1. Allow oral fluids
2. INJ. NEOMOL 1gm/iv/sos
3. TAB. Dolo 650mg/po/TID
4. Vital monitoring 1 hourly
5. Tab. AMLODIPINE 5mg + ATENOLOL 50mg /po/od
6. INJ. HAI 
7. 7 points GRBS Profile

       

21/10/22

22/10/22

S. Decreased appetite,

Nausea

O:  2fever spikes  104°f , and 102°f 

O/e

Patient conscious ,coherent ,cooperative

Temperature 99.6 f

Bp:140/90mmhg

PR: 84bpm

RR: 21 cpm

CVS: S1;S2 + no murmurs

RS: BAE+ NO  added sounds

P/A : soft ,  Tenderness in epigastric , right hypochondrial pain ,BS+

CNS: HMF intact no FND

Course in hospital 

A 72yr old post menopausal female presented to our casualty with complaints of fever since sep15th ( 36th day of iliness). high grade continuous type associated with chills and rigors 

not associated with nausea and vomiting/headache/cold/cough. 

H/o Early morning( 12-2am ) fevers 

With every 2 days 

And continuous fevers through out the day since 4-5 days 

History of UTI was present and subsided with no longer symptoms of burning micturition, increased frequency and urgency

She was treated with oral medicines on day 2 of illness and fever hadn't subsided. It was not associated with loose stools /blood in stools 

On 2nd October (17th day of illness ) she was given IV antibiotics for 2 days, and was on antipyretics 

From 9th October she again had a fever spike, she consulted a doctor, she was started on in. Magnexforte and Tab. Farepeneum 200mg for a week

"presented to outside hospitalwith fever, right hypochondriac pain and nausea, she was clinically as SEPSIS WITH MODS, surgical opinion was taken and adviced for lap cholecystectomy for acalculous cholecystitis, but they refused. advised to get CECT abdomen but she got chills after a test dose of A contrast. The physician thought of melioidosis and started on Meropenem Blood and urine cultures were not done

As told by the doctor

On 19/10/22, they are referred to our hospital

72y/f  pyrexia of unknown origin ,

UTI , k/c/o t2 DM  since 22 yrs and HTN since  20 yrs

Heart failure with presented ejection fraction with Rt  middle  lobe consolidation ?TB with collapse  with Rt mild pleural effusion.

*Allow oral feeds

1)Ivf-1Ns with optineuron @75ml

2) Inj Neomol 1gm Iv sos if temp > 101°f

3) Inj human actrapid insulin s/c TID

4)Tab.Aten.Am 15 MG PO /OD

5)Tab.Dolo 650 mg po/ TID

6)GRBS charting

7)BP/PR/Temp/RR charting

8)InJ lasix40 mg  iv /bd

9)inj ceftriaxone 1gm iv/ bd( day 2)

10) Tab Doxy 100mg po/bd ( day 2)

11) Tab ultracet  half tablet sos

12) syrup cremaffin plus 15ml/po/Hs

USG guided pleural tap was done  on 22/10/22 and sent for investigations 

OBGY referral I/v/o PUO related to gynecological cause

21/10/22

72y/f  pyrexia of unknown origin ,

UTI (resolved) , k/c/o t2 DM  since 22 yrs and HTN since  20 yrs

Heart failure with preserved ejection fraction with Rt   upper &middle  lobe consolidation  with collapse  with Rt mild pleural effusion?TB

S. Decreased appetite,

Nausea

O:  1fever spikes  100°f 

O/e

Patient conscious ,coherent ,cooperative

Temperature 99.6 f

Bp:110/60mmhg

PR: 88bpm

RR: 21 cpm

CVS: S1;S2 + no murmurs

RS: BAE+ NO  added sounds

P/A : soft ,NoTenderness ,BS+

CNS: HMF intact no FND

I/o - 1900/1450 ml

*Allow oral feeds

1)Ivf-1Ns with optineuron @75ml

2) Inj Neomol 1gm Iv sos if temp > 101°f

3) Inj human actrapid insulin s/c TID

4)Tab.Aten.Am 15 MG PO /OD

5)Tab.Dolo 650 mg po/ TID

6)GRBS charting

7)BP/PR/Temp/RR charting

8)InJ lasix40 mg  iv /bd

9)inj ceftriaxone 1gm iv/ bd( day 3)

10) Tab Doxy 100mg po/bd ( day 3)

11) Tab ultracet  half tablet sos

12) syrup cremaffin plus 15ml/po/Hs

13)syrup Arystozyme 15ml /po/Tid before food

24/10/22

72y/f  pyrexia of unknown origin ,

UTI (resolved) , k/c/o t2 DM  since 22 yrs and HTN since  20 yrs

Heart failure with preserved ejection fraction with Rt   upper &middle  lobe consolidation  with collapse  with Rt mild pleural effusion?TB

S. Appetite improved 

O:  no fever spikes

O/e

Patient conscious ,coherent ,cooperative

Temperature 98.6 f

Bp:120/80mmhg

PR: 84bpm

RR: 19cpm

CVS: S1;S2 + no murmurs

RS: BAE+ NO  added sounds

P/A : soft ,NoTenderness ,BS+

CNS: HMF intact no FND

I/o - 1650/1150 ml

*Allow oral feeds

1)Ivf-1Ns with optineuron @75ml

2) Inj Neomol 1gm Iv sos if temp > 101°f

3) Inj human actrapid insulin s/c TID

4)Tab.Aten.Am 15 MG PO /OD

5)Tab.Dolo 650 mg po/ TID

6)GRBS charting

7)BP/PR/Temp/RR charting

8)InJ lasix40 mg  iv /bd

9)inj ceftriaxone 1gm iv/ bd( day 3)

10) Tab Doxy 100mg po/bd ( day 3)

11) Tab ultracet  half tablet sos

12) syrup aystozyme 15ml /po/Tid before food 

25/10/22

72y/f  pyrexia of unknown origin ,

UTI (resolved) , k/c/o t2 DM  since 22 yrs and HTN since  20 yrs

Heart failure with preserved ejection fraction with Rt   upper &middle  lobe consolidation  with collapse  with Rt mild pleural effusion?TB

S. Appetite improved 

O:  no fever spikes

O/e

Patient conscious ,coherent ,cooperative

Temperature 97.6 f

Bp:130/80mmhg

PR: 86bpm

RR: 18cpm

CVS: S1;S2 + no murmurs

RS: BAE+ NO  added sounds

P/A : soft ,NoTenderness ,BS+

CNS: HMF intact no FND

I/o - 1400/1250 ml

*Allow oral feeds

1)Ivf-1Ns with optineuron @75ml

2) Inj Neomol 1gm Iv sos if temp > 101°f

3) Inj human actrapid insulin s/c TID

4)Tab.Aten.Am 15 MG PO /OD

5)Tab.Dolo 650 mg po/ TID

6)GRBS charting

7)BP/PR/Temp/RR charting

8)InJ lasix40 mg  iv /bd

9)inj ceftriaxone 1gm iv/ bd( day 3)

10) Tab Doxy 100mg po/bd ( day 3)

11) Tab ultracet  half tablet sos

12) syrup aystozyme 15ml /po/Tid before food