A 50 yr old female came to OPD with fever.

21 August 2022 

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Mamta Agrawal

Roll no. 42

A 50 yr old woman farmer by occupation resident of nakrekal presented to op with chief complaints of fever and swelling on both legs

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 days back. Then she developed fever which was insidious in onset intermittent in nature and relieved on medication(dolo) and increases during night time around 4 AM. 5 days before the onset of fever she was travelling to nearby villages in rains and had decreased appetite and has also been working on her farms. 

There is history of swelling in the foot which was gradual and associated with onset of fever and has decreased since 2 days. 

There is a history of loose stools 5 days back with 4 episodes which was because of intake of Vamu ( Ajwain) , ( which she normally takes due to her constipation i.e., she has bowel movements once every 3 days and every time before she had normal motions but this time it was diarrhea) and associated with pain for half an hour in lower abdomem after her present bowel movement ? Pain. 

She has history of association pain in the lower limbs from waist to toe which is dragging type and present everytime she moves her legs since 5 days. 

She has an history of vomiting 2 days back of 3 episodes everytime she consumes food which was associated with nausea and had food as it contents. 

She visited the local hospital 4 days back where she had some test done which reported to have low platelets count and she was referred to our hospital for further care and investigation. 

PAST HISTORY:

She is not an known case of Diabetes Hypertension Asthma Lerposy and Epilepsy

She has a surgical history of hysterectomy done 20 yes back. 

FAMILY HISTORY:

Not significant

PERSONAL HISTORY:

Diet - Mixed

Appetite - Decreased since long time and further reduced since last 5 days

Bowel and bladder - Constipation since 2 yrs and diarrhea 5 days back. 

Sleep - Adequate

Drugs - Toddy occasionally on festives. 

Allergies - none. 

24 HR RECALL:

1 idli yesterday evening 

And rice after some time

And 1 idli in the morning today. 

GENRAL EXAMINATION:

Patient is conscious coherent and co operative well oriented to time place and person. 

Patient was examined in a well lit room and consent was taken.

Vital -

PR-75bpm

BP-110/70

RR-16cpm

SPo2-98%

Temp-Afebrile

Pallor - Absent

Icterus - present

Clubbing - Absent

Cyanosis- Absent

Lymphadenooathy- Absent

Edema - B/l pedal edema

SYSTEMIC EXAMINATION-

CVS-

S1, S2 heard

Resp

NVBS

CNS-

NFD

PER ABDOMEN-

Soft and non tender

INVESTIGATION-

NS1 , Ig G, Ig M :- Negative

Haemogram-

Fever chart -

ECG -

Radiological investigations :-

Blood urea levels - 

On 21/08 - 144mg/dl (12-42) 

On 22/08 - 123mg/dl

Creatinine levels-

On 21/08 - 3.8mg/dl (0.6-1.1) 

LFT-

PROVISIONAL DIAGNOSIS-

AKI secondary to Leptospriosis

PLAN OF TREATMENT-

1.IVF - ns, RL @75ml/hr

2.Tab. Pan 40mg PO/OD

3.Tab. Zofer 4mg PO/ BD

4.Tab. paracetamol 650mg PO/TID

5.INJ. Neomol IV / SOS if temp >102°

6Temperature monitoring 4th hourly

7.Strict vitals monitoring - BP,PR 2nd hourly