An 80 year old female with pyrexia

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based input.

CHIEF COMPLAINT:
Pt complaints of fever since 15 days and headache since 1 week 

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 weeks back then she developed fever which is intermittent fever associated with headache and was not relieved on medication.
Fever is aggrevated at night
H/O headache
No history of vomitings
No history of loss of appetite 
No history of SOB

PAST HISTORY:
H/o thrombocytopenia 
Not a known case of hypertension, diabetes, epilepsy, asthma.

FAMILY HISTORY: 
No family history

PERSONAL HISTORY: 
Diet- mixed
Appetite- normal 
Bowel and bladder movements- Regular
Allergies- No
Addictions- No

GENERAL EXAMINATION:
Pt is conscious, coherent and cooperative and well oriented to time,place and person.
No pallor,icterus,cyanosis clubbing,edema, malnutrition. 

VITALS-
TEMP- 101°c
BP- 110/70 mmHg 
Pulse rate-150bpm
RR- 16cpm


SYSTEMIC EXAMINATION:

CVS- S1 S2 heard
No thrills and murmurs 

RS- BAE+
Trachea central

Abdomen: Shape-scaphoid
No tenderness
No palpable mass
Liver and spleen not palpable 

CNS: conscious &alert  
ECG
PROVISIONAL DIAGNOSIS: 
pyrexia with bacterial infection 

INVESTIGATIONS: 

Widal test: positive 
CBP
RFT
LFT

FINAL DIAGNOSIS: 
Pyrexia with septic shock and headache 

TREATMENT :
IV fluids
Inj. NEOMOL
Inj. MONOCEF
Tab. DOLO 650mg







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