50 year old female with fever since one month and vomitings since 7 days

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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 inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome. 

CHIEF COMPLANTS:-

50 year old female came with complaints of fever since 1 week associated with vomitings

HISTORY OF PRESENT ILLNESS:-

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. 

Pt also have complaints of Right shoulder pain since 1 month with bilateral knee pain since 6 months.

Right shoulder pain associated with restriction of movement and Not associated with morning stiffness.

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

PERSONAL HISTORY:-

Occupation:- Daily wage worker,used to work for 8-10 hrs and now she has stopped working since one month due to fever and body pains.

Diet:- Mixed

Bowel and Bladder:- Regular

Appetite lost since 1 week

No known allergies

Addictions:- Tobbacco( Chewable )for 1 year, stopped one month back.

Attained menopause 5 months back.

GENERAL EXAMINATION:-

Patient is conscious , coherent & co-operative

Moderately built and nourished.

No signs of pallor, icterus, clubbing, cyanosis, pedal edema and lymphadenopathy.

Vitals @ admission 

Temp - 99.2F

RR -18CPM

PR - 132BPM

BP - 140/80mmHg

Spo2 - 99% RA

SYSTEMIC EXAMINATION:-

Respiratory system:-

Bilateral air entry present 

NVBS heard

Cardiovascular system:-

S1, S2 heard

CNS:-

NFND

Abdomen:-

Soft, Non tender

Clinical Images:-

INVESTIGATIONS:-

Hemogram

CUE

LFT

Blood urea

Serum Creatinine

Serum Electrolytes

RBS

Uric acid

CRP

ESR

Serology 

Thyroid profile:-

ECG

2D Echo

USG neck:-

Chest X ray:-

Right knee X ray(AP and lateral view):-

Left Knee X ray(AP and lateral view):-

Right Shoulder X ray(AP and Axillary view) :-

Fever chart:-

PROVISIONAL DIAGNOSIS:-

Hyperthyroidism(Thyrotoxicosis) 

TREATMENT:-

On 11/5/23:-

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 4th hrly

7) Vitals monitoring 4th hrly

On 12/5/23:-

Ortho refferal done on 12/5/23 I/V/O b/l knee pain since 6 months and right shoulder pain since 1 month and advised Tab.Febuxostat 40mg OD and Tab.Hifenac -P. 

Cardiology refferal done on 12/5/23 I/V/O persistent tachycardia and advised Tab.MET XL 25 mg OD.

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

On 13/5/23:-

ENT refferal done on 13/5/23 and diagnosed as Laryngopharyngeal reflux disease and advised usg neck and upper GI endoscopy, treated with candid oral paint, zytee, syp. Sucrafyl. 

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 2nd hrly

On 14/5/23:-

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

8)Temp monitoring 2nd hrly

9) Vitals monitoring hrly

On 15/5/23:-

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/BDAMC Bed 3

6)PROPONOLOL 40mg Po/BD

7)TAB .CARBIMAZOLE 10mg PO/TID

8)BETADINE 3% GARGLES

9)Temp monitoring 2nd hrly

10)Vitals monitoring hrly

On 16/5/23:-

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)PROPONOLOL 40mg Po/BD

7)TAB .CARBIMAZOLE 10mg PO/TID

8)BETADINE 3% GARGLES

9)Temp monitoring 2nd hrly

10)Vitals monitoring hrly

On 17/5/23:-

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)PROPONOLOL 40mg Po/BD

7)TAB .CARBIMAZOLE 10mg PO/TID

8)BETADINE 3% GARGLES

9)Temp monitoring 2nd hrly

10)Vitals monitoring hrly

On 18/5/23:-

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)PROPONOLOL 40mg Po/BD

7)TAB .CARBIMAZOLE 10mg PO/TID

8)BETADINE 3% GARGLES

9)Temp monitoring 2nd hrly

10)Vitals monitoring hrly

On 19/5/23:-

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)PROPONOLOL 40mg Po/BD

7)TAB .CARBIMAZOLE 10mg PO/TID

8)BETADINE 3% GARGLES

9)Temp monitoring 2nd hrly

10)Vitals monitoring hrly

On 20/5/23:-

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)PROPONOLOL 40mg Po/BD

7)TAB .CARBIMAZOLE 10mg PO/TID

8)BETADINE 3% GARGLES

9)Temp monitoring 2nd hrly

10)Vitals monitoring hrly

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

On 21/5/23:-

Psychiatry refferal done on 21/5/23 I/v/o delirium

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)PROPONOLOL 40mg Po/BD

7)TAB .CARBIMAZOLE 10mg PO/TID

8)BETADINE 3% GARGLES

9)Temp monitoring 2nd hrly

10)Vitals monitoring hrly

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

On 22/5/23:-

Surgery refferal done on 22/5/23 I/v/o neck swelling which on ultrasound showed diffuse thyroiditis TIRADS 3 lesion in left lobe of thryoid , diagnosed as Diffuse Goitre and advised FNAC. 

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)PROPONOLOL 40mg Po/BD

7)TAB .CARBIMAZOLE 10mg PO/TID

8)BETADINE 3% GARGLES

9)Temp monitoring 2nd hrly

10)Vitals monitoring hrly

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

On 23/5/23:-

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)PROPONOLOL 40mg Po/BD

7)TAB .CARBIMAZOLE 10mg PO/TID

8)BETADINE 3% GARGLES

9)Temp monitoring 2nd hrly

10)Vitals monitoring hrly

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

My Questions regarding this case

1.Why is fever not subsiding even after taking medications (Antibiotics outside)? 

2.what could be the cause of fever in this case, TLC being normal? 

3.What could be the reason for sinus tachycardia in this patient? 

4.How is arthirtis of knee and fever interlinked in this case?