General medicine case 3

  A 74 yr old female with fever

September 21 , 2021

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. 

Unit 1 admission 

Amc

Date of admission: September 14 , 2021

A 74 year old female came with complaints of fever since 4 days,generalised weakness since 4days

 two episodes of vomiting 1 day ago 


History of present illness:

Pt was apparently asymptomatic 4 days ago,c/o fever,highgrade,intermittent,not associated with chills and rigors 


Associated with generalized weakness, two episodes vomitings,subsided on its own


 Shortness of breath on exertion then progressed to shortness of breath on rest  

 pericardial effusion 1year ago,diagnosed,on medication for 6 months later subsided


No h/o orthopnea, dyspnea

No pain  abdomen,loose stools


Past history:


 Dm since 3 years


hypothyroidism since 10 years on regular medication


Personal history:


Diet:mixed


Appetite:normal


Bowel,Bladder:regular


No addictions 


General examination 


Pt is coherent, conscious and well oriented with place and person.


Pallor+,no icterus,cyanosis, clubbing, lymphadenopathy,edema

Vitals

Pr-86bpm

Bp-100/70mmhg

Rr-24cpm

Spo2-95%@RA

Grbs-146mg/dl



Systemic examination 

Cvs-s1,s2+

Rs-crepts+

Nvbs

P/a:

Soft,nontender

No palpable mass

Cns-intact



Provisional diagnosis:


 LEPTOSPIRA WITH RENAL AKI WITH UREMIC ENCPHALOPATHY WITH HEPATIC ENCEPHALOPATHY GRADE 1 ( RESOLVED)


WITH DM -2 , HTN  , HYPOTHYROIDISM


Investigations:

Plt at time of admission- 20,000/ cu.mm

Aptt-41.0

Inr-1.21

Dengue Ns1-negative

DengueIgG-negative

Dengue IgM-negative

Serology- negative

Chest x ray-

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