50F with pyrexia under evaluation

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 50 year old female, health care worker ( aayamma in orthopedic hospital ) resident of miryalguda presented with complaints of fever since 1 week, nausea and vomitings for 3 days, Rt shoulder pain since 1 week.


She works in a orthopaedic hospital, does washing of patients clothes, OT gowns, other clothes with cleaning the hospital premises when ever it’s necessary. After reaching home she manages to do her work and take rest.

In 2005 when her parents went to daily work ( daily waged labourers ) met with an road accident and expired, following which in there memory she tattooed there names on her right forearm. ( similar tattoos where present on her both knees, couldn’t give exact reason for them ).

Since 10-11 year she had both knee joint pains for which she took analgesics with a frequency of 4-5 per month which did not effected her daily routine. Her son got married 10 years back, with daughter in law entering into her family, she got some rest and continues to work in hospital.

Since 1 year her knee joint pains has increased and worsened 4-5 months back with difficulty in walking. She reached an orthopaedician and received a shot of intra articular injection ( presumably steroids ) following which she get some relief and managed to do her work.

Since 4 months she had low grade fever, intermittent, episode lasting for 7-14 days with complete normalcy in between the episodes and associated with progressive worsening of knee pains. Since February 28th till date ( 2 1/2 months = 70 days ) she had 4-5 hospital visits which reveals persistent tachycardia, lower blood pressure ( SBP 80-90 mmhg ), documented elevation of inflammatory markers ( ESR, CRP ) 1 month back. Received Antibiotic cocktail ( piptaz, doxy, clindamycin, magnet forte ) in last 1 month.
On 18 th April she went to local physician in miryalguda and admitted, where her examination revealed tachycardia with HR 135 at normal body temp and blood pressure of 80/60 mmhg. Normal hemogram, Renal and liver functions. She was tested negative for widal ( titers < 1:80 ), Dengue, malaria and HIV serology.ECG showing sinus tachycardia with S1Q3T3. In view of further work up of pulmonary embolism / myocarditis she was referred to higher centre next day morning.

In Nalgonda work up for Pulmonary Embolism ( here after referred as PE ) was done with echo showing Normal sized chambers with No RWMA and Good LV systolic function. D dimers was slightly elevated with an rough value around 1100 IU/dl ( normal < 250-400). USG abdomen - normal study except renal calculi. In view of elevated D dimer and clinical distress ( tachypnea and spO2 94-95 on RA) CTPA was done which shows Negative study for PE. Patient denied further work up and get got symptomatic treatment and returned to her home. She was symptomatically improving and started to go to work after 5-6 days. 

10 days back she had attended a marriage where she ate mutton curry following next day she had fever initially low grade, progressed to high grade with in 2 days associated with 3-5 episodes of vomitings, which was initially non bilious with last episode of bilious vomiting with food particles as contents and no blood. She reported generalised weakness and loss appetite with decreased meal consumption, she used to chew tobacco regularly since yrs which was stopped after this fever episode. She revealed appearance of oral ulcers and throat pain coinciding with fever. She also briefed about her right shoulder pain which was insidious in onset rapidly progressed over 3-4 days with difficulty and pain during movements around the joint which hampered her activities of daily living. 
 

C/O FEVER SINCE 1 WEEK ASSOCIATED WITH VOMITINGS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 30 DAYS BACK THEN SHE DEVELOPED FEVER OF HIGH GRADE WITH CHILLS AND RIGORS FOR WHICH SHE GOT ADMITTED IN HOSPITAL AND TREATED , FEVER RELIVED ON MEDICATION.

SINCE 1 WEEK SHE DEVELOPED FEVER OF HIGH GRADE WITH CHILLS AND RIGORS, CONTINUOUS RELIEVED ON MEDICATION BUT RECURRING AFTER 3-4 HRS, GENERALISED WEAKNESS PRESENT, DRY MOUTH PRESENT, VOMITINGS PRESENT 2-3 EPISODES PER DAY SINCE 1 WEEK , NON BILIOUS, PROJECTILE, CONTAIN FOOD PARTICLES, 1 EPISODE OF BILIOUS VOMITING TODAY MORNING, NAUSEA PRESENT, LOSS OF APETITE PRESENT.

NO H/O LOSS OF WEIGHT, SORE THROAT, COUGH, COLD, ABDOMINAL PAIN , DIARRHEA, BURNING MICTURITION.

PAST HISTORY:

N/K/C/O DM, HTN, THYROID, ASTHMA, CAD, CVA, EPILEPSY

FAMILY HISTORY : INSIGNIFICANT

GENERAL EXAMINATION:

PATIENT IS C/C/C

NOPALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,ODEMA.

VITALS: TEMP: 100.8 F

PR:134 BPM

BP:130/80

RR:20 CPM

SPOI2: 98%

GRBS:102 MG%

SYSTEMIC EXAMINATION:

CVS:S1,S2 +

CNS:NAD,

RS:BAE+, NAD.

PA:SOFT,NONTENDER, NO ORGANOMEGALY

 

CARDIOLOGY REFFERAL DONE ON 12/5/23 I/V/O PERSISTENT TACHYCARDIA (MORE THAN 110-120 BPM) ,AND ADVISED TAB.MET-XL 25 MG PO/OD.

ORTHOPAEDICS REFFERAL DONE ON 12/5/23 I/V/O B/L KNEE JOINT PAIN AND RIGHT SHOULDER PAIN ,AND ADVISEDTAB.FEBUXOSTAT 40MG PO/OD (

ENT REFERRAL DONE ON 13/5/23 DIAGNOSED AS LARYNGOPHARYNGOREFLUX DISEASE ADVISED USG NECK AND UPPER GI ENDOSCOPY TREATED WITH CANDID ORAL PAINT,ZYTEE,SYP.SUCRAFYL

PSYCHIATRY REFERRAL DONE ON 21/5/23 I/V/O DELIRIUM ADVISED

SURGERY REFERRAL DONE ON 22/5/23 I/V/O NECK SWELLING WHICH ON ULTRASOUND SHOWED DIFFUSE THYROPIDITIS TIRADS 3 LESION IN LEFT LOBE OF THYROID  DIAGNOSE AS DIFFUSE GOITRE AND ADVISED FNAC

 









INVESTIGATIONS :

2D ECHO

USG NECLK- DIFFUSE THYROIDITIS, TIRADS 3 LESION IN LEFT LOBER OF THYROID

USG RIGHT SHOULDER _BICEPS TENDINITIS,DEGENERATIVE CHANGES WITH INTERSTITIAL TEARS NOTED IN PASRT OF SUPRASPINATUS, SUBCORTICAL BURSITIS

USG ABDOMEN_ BULKY LEFT KIDNEY WITH ALTERED ECHOTEXTURE WITH UPPERPOLE CALCULUS

ENDOSCOPY- SMALL HIATUSERNIA

ECG; NORMAL SINUS RHYTHM, SINUS T HACHYCARDIA











 

HEMOGRAM:

HB-11.5,11.6,11.5

TLC-9300,6600,6200

PLT-2.66'2.04,2.44


COURSE IN HOSPITAL:

 TREATMENT GIVEN

I V FLUIDS NS,RL@ 75ML/HR

IMJ.NEOMOL 1GM IV/SOS

INJ.PAN 40MG IV/OD

INJ.ZOFER 4 MG IV/SOS

T.DOLO 650 MG PO/TID

T.PROPONOLOL 40 MG PO/BD

CANDID ORAL PAINT LA TID

ZYTEE GEL AFTER FOOD TID

BETADINE 3% GARG
 
ADVICE AT DISCHARGE:
 

 TAB . CARBIMAZOLE 10MG/PO/TID

 

TAB. PROPONOLOL 20MG PO/TID

 

TAB TELMA 40MG PO/OD

 

TAB ULTRACET  PO/BD FOR 2 DAYS

 

TAB OLANZAPINE 5MG PO/HS

 

TAB.PAN 40MG PO/OD

 

TAB.TENDOCARE PO/OD

 

TAB.SHELCAL PO/OD

 

SYSTAPHLEM GEL FOR L/A

 

SYP. LACTULOSE 15ML PO/TID

 

 

SYP POTKLOR 10 ML/PO/TID WITH GLASS OF WATER

S

AMC Bed 3

14.05.23

50 year old female


 A

pyrexia under evaluation

S 

drowsy

difficulty in swallowing increased

Fever spikes present

loss of appetite , appetite decreased comparitively

Complaints of knee pain decreased when compared to the day of admission

Stools not passed


O

Patient is c/c/c

Temp:- 99.2

PR- 149bpm

RR - 38cpm

BP-  140/80mmHg

GRBS- 96mg%


CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,NT

CNS - NFND


A

Pyrexia under evaluation




P:

1)IV fluids NS, RL @ 75ml/hr

2) Inj. neomol 1g/IV/SOS (If temp >101°F) 

3) Inj. Zofer 4mg/PO/SOS

4)Tab. PAN 40mg PO/OD

5)Tab.Dolo 650mg PO/BD

6)Temp monitoring 2nd hrly

7) Vitals monitoring  hrly

AMC Bed 3

15.05.23

50 year old female


 

S 

drowsy

cannot sleep  yesterday night .

difficulty in swallowing decreased

Fever spikes present with chills

appetite increased comparitively but cannot eat due to bitter tongue

Complaints of knee pain decreased when compared to the day of admission

complaints of shoulder pain , not decreased

Stools not passed


O

Patient is c/c/c

Temp:- 99.8

PR- 131bpm

RR - 38cpm

BP-  180/100mmHg



CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,NT

CNS - NFND


A

HYPERTHYROIDISM 




P:

1)IV fluids NS, RL @ 75ml/hr

2) Inj. neomol 1g/IV/SOS (If temp >101°F) 

3) Inj. Zofer 4mg/PO/SOS

4)Tab. PAN 40mg PO/OD

5)Tab.Dolo 650mg PO/BD

6)Temp monitoring 2nd hrly

7) Vitals monitoring  hrly

8)PROPONOLOL 40mg Po/BD

9)TAB .CARBIMAZOLE 10mg PO/TID

10) BETADINE 3% GARGLES

AMC Bed 3

16.05.23

50 year old female


 

S 

drowsy more than yestersay

difficulty in swallowing decreased.

Cannot hold neck.

Fever spikes present 

appetite decreased 

Complaints of knee pain decreased when compared to the day of admission

complaints of shoulder pain , not decreased

Stools passed.


O

Patient is c/c/c

Temp:- 98.8

PR- 148bpm

RR - 28cpm

BP-  140/80mmHg

GRBS- 70 mg%


CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,NT

CNS - NFND


A

HYPERTHYROIDISM 




P:

1)IV fluids NS, RL @ 75ml/hr

2) Inj. neomol 1g/IV/SOS (If temp >101°F) 

3) Inj. Zofer 4mg/PO/SOS

4)Tab. PAN 40mg PO/OD

5)Tab.Dolo 650mg PO/BD

6)Temp monitoring 2nd hrly

7) Vitals monitoring  hrly

8)PROPONOLOL 40mg Po/BD

9)TAB .CARBIMAZOLE 10mg PO

/TID

10) BETADINE 3% GARGLES

AMC Bed 3

17.05.23

50 year old female


 

S 

drowsy 

sleep cycle altered

difficulty in swallowing decreased.

Cannot hold neck.

Fever spikes present 

appetite decreased , nausea vomiting +

Complaints of knee pain decreased when compared to the day of admission

complaints of shoulder pain , increased

Stools passed.


O

MMSE:

Orientation to time +5

Orientation to place : +5

registration: +1

Attention: 1

Recall:1

Naming:2

Repitition:1

doing and obey: 0

sentence:1

copying:1

MMSE :(18/30)

Patient is c/c/c

Temp:- 98.8

PR- 112bpm

RR - 27cpm

BP-  140/80mmHg

GRBS- 112mg%


CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,NT



A

HYPERTHYROIDISM 




P:

1)IV fluids NS, RL @ 75ml/hr

2) Inj. neomol 1g/IV/SOS (If temp >101°F) 

3) Inj. Zofer 4mg/PO/SOS

4)Tab. PAN 40mg PO/OD

5)Tab.Dolo 650mg PO/BD

6)Temp monitoring 2nd hrly

7) Vitals monitoring  hrly

8)PROPONOLOL 40mg Po/BD

9)TAB .CARBIMAZOLE 10mg PO/TID

10) BETADINE 3% GARGLES

AMC Bed 3

18.05.23

50 year old female


 

S 

drowsy 

sleep cycle altered

difficulty in swallowing decreased.

Fever spikes present 

appetite decreased , nausea vomiting +, non projectile ,non bilious  associated with nausea 2 times in last day

Complaints of knee pain decreased when compared to the day of admission

complaints of shoulder pain , increased

Stools passed.


O

MMSE:



Patient is c/c/c

Temp:- 98.8

PR- 128bpm

RR - 27cpm

BP-  150/90mmHg

GRBS- 109mg%


CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,NT



A

HYPERTHYROIDISM 




P:

1)IV fluids NS, RL @ 75ml/hr

2) Inj. neomol 1g/IV/SOS (If temp >101°F) 

3) Inj. Zofer 4mg/PO/SOS

4)Tab. PAN 40mg PO/OD

5)Tab.Dolo 650mg PO/BD

6)Temp monitoring 2nd hrly

7) Vitals monitoring  hrly

8)PROPONOLOL 40mg Po/BD

9)TAB .CARBIMAZOLE 30mg PO/TID

10) BETADINE 3% GARGLES

Cubicle  Bed 1

21 .05.23

50 year old female


 

S 

drowsy 

Fever spikes present

sleep cycle altered

appetite decreased 

Complaints of knee pain decreased when compared to the day of admission

complaints of shoulder pain , increased

Stools passed.


O: drowsy ,not cooperative



Patient is c/c/c

Temp:- 99.8

PR- 115bpm

RR - 26cpm

BP-  130/80mmHg



CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,NT



A

HYPERTHYROIDISM 




P:

1)IV fluids NS, RL @ 75ml/hr

2) Inj. neomol 1g/IV/SOS (If temp >101°F) 

3) Inj. Zofer 4mg/PO/SOS

4)Tab. PAN 40mg PO/OD

5)Tab.Dolo 650mg PO/BD

6)Temp monitoring 2nd hrly

7) Vitals monitoring  hrly

8)PROPONOLOL 40mg Po/BD

9)TAB .CARBIMAZOLE 10mg PO/TID

10) BETADINE 3% GARGLES

11) Inj KCL 2amp (50mEq) in 500ml NS/IV slowly over 5 hours/STAT.

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