A 70Y OLD FEMALE WITH RECURRENT FEVERS
CHIEF COMPLAINTS:
A 70y old patient initially came to ophthalmology opd on 03/02/2024 with complaints of diminishing of vision in the Right eye since 1year
HOPI:
[The patient was apparently asymptomatic 1year ago, then she developed diminishing of vision in Right eye, which is insidious in onset and gradually progressive.
Watering of eyes present (left > right) since 1year
H/o pricking type of sensation present in both eyes since 1month
No h/o trauma or redness in the eyes]
After admitting into ophthalmology department, the patient developed Fever on 04/03/2024 morning, which is sudden in onset, high grade, associated with chills and rigors.(on & off).
The patient is then transferred to the Medicine department given her fever history.
H/o dull Abdominal pain since 3days
No h/o Burning micturition, decreased urine output or blood in urine.
No h/o cold and cough
No h/o vomitings, loose motions
PAST HISTORY:
K/C/O DM and HTN since 8years (on medication)
Not a K/C/O Asthma, TB, epilepsy, CAD, CVD, Thyroid disorders
[The patient had several episodes of fever in the last 6months. The most recent episode being 10days ago.
Low-moderate grade,
Not associated with chills and rigors,
Relieved with medication (Dolo-650),
Sometimes , she used to take medicines from a local hospital at suryapet, if the fever is not subsiding.]
SURGICAL HISTORY:
The patient underwent Hysterectomy 20years ago.
PERSONAL HISTORY:
Diet -mixed
sleep - adequate
appetite - normal
bowel and bladder- Regular
GENERAL EXAMINATION:
Patient is c/c/c, moderately built and nourished.
Pallor ++,
No Icterus, cyanosis, clubbing, lymphadenopathy, Edema.
Vitals @ Admission:
Temp - 98F
PR-84bpm
BP - 130/70 mmHg
Spo2 - 98% @ RA
RR - 16 CPM
GRBS- 98 mg/dl
SYSTEMIC EXAMINATION:
CVS - S1 S2 +
RS - BAE +, CLEAR,
NVBS.
P/A - Soft, non-tender
CNS- NAD
Rt. Lt.
Vision: CF 2m . NI 6/36 . 6/18 P
IOP: 22 17
Lids: N. Lower lid entropion
Conjunctiva: Muddy Muddy
Cornea: Arcus Arcus
AC: PACD >1/2 CT. PACD >1/2 CT
Iris: NCP. NCP
pupil: NSRL. NSRL
Lens: IMSC NSG grade 2 with central PSC
Dilated Fundus Examination:
Rt. Eye Lt. Eye(6mm)
Media: Hazy Hazy
Disc: N size, circular, well defined margins
CDR: 0.3:1, HNRR 0.3:1, HNRR
Vessels: N. N
Macula: FR not seen FR dull
Retina: Gross Tesellations present (B/E)
[PACD: peripheral anterior chamber depth; HNRR: healthy neuro-retinal rim,CDR: cup-disc ratio, FR: foveal reflex]
INVESTIGATIONS:(04/02/2024)
HEMOGRAM: Hb- 9.5gm /dl
Tlc- 9500cells/cumm
N/L/E/M- 81/15/1/3
PCV- 27.9
RBC- 3.46 millions/cumm
Plt- 2.79 lakhs/cumm
Blood sugar fasting: 127mg/dl
CUE: color: pale yellow
ALB- Nil
Sugar- Nil
Pus cells: 1-2
Epithelial cells: 3-4
RFT:
Urea- 48mg/dl
Serum creatinine- 0.7mg/dl
Blood urea -26mg/l
Uric acid- 5.7
Na/k/cl/Ca/pO4- 138/4.2/101/9.9/2.0
LFT:
TB- 0.56;
DB- 0.19;
AST- 18; ALT-10;
ALP- 134;
TP-6.9;
ALB-4.26
(05/02/2024):
HEMOGRAM: Hb- 8.7gm /dl
Tlc- 9600cells/cumm
N/L/E/M- 79/16/0/5
PCV- 25.1
RBC- 3.13 millions/cumm
Plt- 2.22lakhs/cumm
RFT:
Urea- 48mg/dl
Serum creatinine- 0.9mg/dl
Blood urea -26mg/l
Uric acid- 4.9
Na/k/cl/Ca/pO4- 136/3.5/99/10/3.2
(FEVER CHART):
DIAGNOSIS:
URINARY TRACT INFECTION WITH B/L IMMATURE SENILE CATARCT;
HTN & DM SINCE 8YEARS
TREATMENT:
1) IV FLUIDS NS, RL @ 100ML/HOUR
2) INJ. CIPROFLOX 40MG IV/BD
3) INJ. NEOMOL IV/SOS
4) T. DOLO 650MG PO/QID
5)T. GLIMI M1 PO/BD
