50 F with Drowsiness, vomiting, diarrhea

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50 year old female, health care presented  with complaints of fever since 1 week, nausea and vomitings for 3 days, Rt shoulder pain since 3 days

HOPI

patient was apparently asymptomatic 10 yeras ago since then. she had both knee joint pains for which she took analgesics with a frequency of 4-5 per month which did not effected her daily routine. Her son got married 10 years back, with daughter in law entering into her family, she got some rest and continues to work in hospital.

Since 1 year her knee joint pains has increased and worsened 4-5 months back with difficulty in walking. She reached an orthopaedician and received a shot of intra articular injection ( presumably steroids ) following which she get some relief and managed to do her work.

Since 4 months she had low grade fever, intermittent, episode lasting for 7-14 days with complete normalcy in between the episodes and associated with progressive worsening of knee pains. Since February 28th till date She had 4-5 hospital visits which reveals persistent tachycardia, lower blood pressure ( SBP 80-90 mmhg ), documented elevation of inflammatory markers ( ESR, CRP ) 1 month back. Received Antibiotic cocktail ( piptaz, doxy, clindamycin, magnet forte ) in last 1 month.

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,and lymphadenopathy.

Pedal edema pitting type from ankle below to knees above

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

LOCAL EXAMINATION

INSPECTION:

Swelling present in midline of neck af about 4x4 cms which is moving and deglutition and not moving with protrusion of tongue

Palpation:

No local rise of temparature, single swelling, soft in consistency, absence of nodular pattern

Percussion:Absence of bruit

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. 

DIAGNOSIS:HYPERTHYROIDISM

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

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

08) BETADINE 3% GARGLES

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

Temp monitoring 2nd hrly

Vitals monitoring  hrly