60F with UTI and CAD

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A 60 year old female came to casuality with chief complaints of fever with chills , nausea, vomitings , pain abdomen since 4 days 

Patient was apparantly asymptomatic 4 days ago then she developed fever which is high grade associated with chills , intermittent in nature relieved by medication associated with pain abdomen , with nausea and vomitings

vomitings are non bilious , nonprojectile contains food particles

h/o burning micturition since 4days with no increased frequency in urine 9i

patient complains of chest pain , non radiating type 

COURSE OF EVENTS IN HER LIFE:

patient ,  agricultural labourer works in jowar fields and in poultry , married at a age of 16 

at 18 she attained menarche 

first child birth at 20 year

second child birth at 22 years

She usually eats jowar instead of rice till 40 years , she shifted to rice from 40 years , 

At 42 years patient has excessive bleeding for which hysterectomy has done

at 48 years she had an episode of fever with chills admitted into a hospital ,from which she had known that she is diabetic and hypertensive and started on medication.

At 50 years , surgical debridement to her right foot was done due  to thorn pick  ,2 months bed rest and able to walk after 6 months

At 58 years , she has an episode of severe chest pain relieved on it's own. 

at 60 years , she has again an episode of fever with chills eith nausea, vomitingfor which she has admitted to ICU for 10 days ( managed with foleys ) 

General Examination:

Patient is conscious , coherent and cooperative , well oriented to time place person

Pallor present

coarse facies

cyanosis, clubbing ,lymphadenopathy , edema absent





VITALS :

TEMP- 100.4F

BP- 140/80

PR-89bpm

RR -28cpm

SYSTEMIC EXAMINATION:

Per abdomen: diffuse tenderness present  ,guarding present in hypogastriym.


no organomegaly 

CVS- s1,s2 heard no murmurs

RS- BAE÷,NVBS

CNS- NFND




INVESTIGATIONS 


HEMOGRAM

-----15/5 -  16/5 - 18/5 - 19/5

HB- 12.1  10.6     -10.1 -  9.9

TLC-12000 9400   7600   6200

PLT- 3.45  -  2.8-  314     2.60

PCV-    36.3-32.6- 30.7    30.7

 

ENDOSCOPY ON 16/05/2023

LAX LES

NON EROSIVE ANTRAL GASTRITIS

 

BLOOD C/S: NO GROWTH

URINE C/S: KLEBSIELLA ISOLATED > 100,000  CFU/ML OF URINE ISOLATED

1]IV FLUIDS 1.NS,1.RL @50ML/HR

 

TREATMENT GIVEN
2]INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD

3]INJ.PAN 40MG IV/OD

4]INJ.ZOFER 4MG IV/SOS

5]T.CLINIDIPINE 10MG PO/BD

6] TAB.MET XL 25MG PO/OD

7]TAB.ECOSPIRIN-AV 75/20 PO/HS

8]SYP.SUCRALFATE 10ML PO/TID

9]TAB GLIMI M2 PO/BD

10]TAB.NORFLOXACIN 400MG PO/BD

11]INJ.HUMAN ACTRAPID INDULIN S/C TID

12]INJ.MAGNEX FORTE111.5 GM/IV/TID.

 ADVICE AT DISCHARGE

1.T. CINOD 10 MG PO/BD

2.T. TELMA 40MG PO/OD

3.TAB.MET XL 25MG PO/OD

4.TAB.NORFLOXACIN 400MG PO/BD FOR 4 DAYS

5.TAB GLIMI M2 PO/BD

6.T. ECOSPIRIN AV 75/20 PO/HS

7.TAB PAN 40 MG PO/OD X 4 DAYS

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