55Y Female with FEVER, SOB, PAIN ABDOMEN since 1 MONTH

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A 55-year-old, currently a homemaker presented with the,

CHIEF COMPLAINTS:

1. Fever since 1 month.

2. Dry cough since 1 month.

3. Shortness of breath since 1 month. 

4. Pain abdomen since 1 month.

HISTORY OF PRESENTING ILLNESS:

1.  Patient was apparently asymptomatic 1 month back then she developed Fever.                                    - Low grade, intermittent in nature, insidious in onset, gradually progressive, relieved on taking medication.                                                                                                                                              - Fever increased from the past 4 days and is associated with generalized weakness, headache and body pains.                                                                                                                                        - Not associated with chills and rigors.
2. H/O Shortness of breath since 1 month, initially grade I which was insidious in onset, gradually progressed to grade III since 1 week.                                                                                                 - No h/o orthopnea, PND.
3. H/O dry cough associated with fever episode, increased since 1 week. 
4. H/O Pain abdomen since 1 month in the epigastric region on inspiration.                                             - Insidious in onset, gradually progressive, non-radiating, no aggravating and relieving factors.     - Associated with bloating and distention, nausea (more in the mornings), occasional vomiting episodes - nonbilious, nonprojectile.
5. H/O pain in multiple small joints of hands, knee, shoulders in the last 10 years on and off and has used ayurvedic medicine for the same. 

No H/O Chest pain, palpitations, excessive sweating, loose stools.

DAILY ROUTINE: 

Till 2 years ago, patient worked as a farmer.

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She used to wake up at 5-6AM, have tea/coffee, eat breakfast and left for field work.

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She left around 8-9Am by walk and used to cover 1-2km daily and was home by evening around 

6-7Pm. 

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 She used to work in paddy fields and was involved in cultivation, planting of saplings and processing of grains. 

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Since two years she has been a homemaker who looks after her 3 year old granddaughter and does household chores - cleaning, cooking for four people, bathing and feeding the 3-year-old.

PAST HISTORY:

• Patient was found to have high BP recordings 5-6 months back and used oral medication on and off given by local practitioner.
• Patient is not a known case of Diabetes Mellitus, Thyroid disorders, Seizures, Tuberculosis, Asthma, stroke or any cardiac disorder.
• History of previous surgery - Cataract surgery for left eye 3 years back. 

PERSONAL HISTORY:

• Her appetite has decreased since past 1 week, she consumes a mixed diet.
• Sleep is adequate. 
• Bowel movements decreased since 10 days (constipation) and Bladder movements are normal.
• No history of smoking. 
• Occasional toddy drinker.
• No known food or drug allergies.
• Menstrual History: Attained menopause.

FAMILY HISTORY:

• No similar complaints in the family members.

GENERAL PHYSICAL EXAMINATION:

Examination has been done in a well-lit room in supine and sitting posture after taking informed consent and after reassuring the patient.

• Patient was conscious, coherent, co-operative and well oriented to time, place and person.
• Moderately built and nourished.
• Pallor present.
• No signs of Icterus, Cyanosis, Clubbing, Pedal edema, Generalized Lymphadenopathy.
• JVP normal.   

Vitals:

11/07/2023

Temperature - 102.7F 

Respiratory Rate - 30 cpm

Pulse Rate - 106 bpm

Blood Pressure - 140/90 mm Hg

SpO2 - 97 at room temp

GRBS - 140mg%

12/07/2023

Temperature - 98.6F (Fever spike +)

Respiratory Rate - 20 cpm

Pulse Rate - 98 bpm

Blood Pressure - 130/80 mm Hg

SpO2 - 97% at RA

GRBS - 194mg%

13/07/2023

Patient is conscious, coherent, cooperative.

Pain abdomen increased in intensity, patient not passed stool.

Temperature - 99.8F 

Respiratory Rate - 26 cpm

Pulse Rate - 100 bpm

Blood Pressure - 130/70 mm Hg

SpO2 - 92% at RA; 99% at 2L o2

14/07/2023

Patient is conscious, coherent, cooperative.

Pain abdomen increased in intensity since last 3 days, associated with 3 episodes of bilious vomitings, non-projectile, non-blood stained, non-foul smelling. 

Stools passed today (greenish in colour)

Temperature - 100F (Fever spike +)

Respiratory Rate - 30 cpm

Pulse Rate - 104 bpm

Blood Pressure - 130/80 mm Hg

SpO2 - 90% at RA, 98% at 2L o2

SYSTEMIC EXAMINATION:

Central Nervous System:  No abnormality detected.

Per Abdomen: 

Distended

Guarding + in right hypochondrium

Tenderness in epigastrium and right hypochondrium +

Bowel sounds +

Hepatomegaly +

Cardiovascular System:

On Inspection: -

1. Precordium:

• No precordial bulges.
• No engorged veins.
• No scar/sinus.
• No epigastric pulsations

2. Chest wall Defects: None.

 On Palpation:-

• Apical beat can be localized 1cm lateral to the midclavicular line in the 6th Intercostal Space.
• Palpable P2 +
• Parasternal Heave: Absent

On Percussion: -

Cardiac dullness

On Auscultation: -

• S1, S2 heard.
• No murmurs heard.

Respiratory System: 

• Crepitations heard in B/L Basal lung areas (ISA and IAA).
• Bilateral air entry is present. 
• Normal vesicular breath sounds are heard.

INVESTIGATIONS:

10th JULY

1. CBNAAT: Negative

11th JULY

1. Serum creatinine: 1.3 mg/dl (normal 0.6-1.2)

2. Blood Urea: 41 mg/dl (normal 12-42)

3. RBS: 121mg/dl

12th JULY

Fair LV function. Diastolic dysfunction +. No PAH/PE.

 

13th JULY

Abdomen erect X-ray: 

15th JULY

Serum Creatinine: 1.1mg/dl

Blood Urea: 43mg/dl

PROVISIONAL DIAGNOSIS:

?Community Acquired Pneumonia (?Bacterial  ?Atypical)

with CAD (HPef)

with Paralytic Ileus

- With ?Subacute Intestinal Obstruction

- With Renal Non-Oliguric AKI 

- With Liver Abscess (10% Liquefaction)

TREATMENT:

1. NBM till further orders 

2. Ryles Tube aspiration

3. IVF NS, RL @ 75ml/hour. 

4. Inj PARACETMOL 1g/IV/SOS (if temp > 101F)

5. Inj PAN 40mg IV/OD

6. Inj PIPTAZ 2.25g IV/TID

7. Inj ZOFER 4mg IV/SOS

8. Inj METROGYL 500mg IV/TID

9. Inj TRAMADOL 1 amp in 100ml NS IV/SOS

10. Inj DROTIN PV/BD