65yr old Female with fever

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65yr Female Patient came to the casuality with c/o fever since 1week
Patient was apparently asymptomatic 5yrs back .
Later diagnosed with HTN 5yrs back on visiting hospital for knee pain.
On medications tab.Telmisartan-40mg OD
Patient was diagnosed with DM 4yrs back on visiting hospital for regular check up
On medication tab .Metformin
Stopped medication since 6 months for the low sugar levels.
6 months back patient went to hospital for pedal edema since 1month.
Patient was daignosed with CKD 6months back.

Patient went to the hospital 2months back for the frothy urine.
Now Patient came to the casuality with c/o fever since 1week.
High grade fever associated with chills and generalised weakness
O/E:
Pt is lethargic.
Febrile
Pr: 102bpm
Bp:  150/70mmhg
Spo2:  99@ RA
GRBS: 96mg/dl
RR: 14cpm.
RS: BAE+
CVS: S1 S2+
Cns: patient is lethargic
GCS: E3V1M6
Pupils: NSRL
Power: Moving all limbs.
Tone: normal
Reflexes      B   T   S   A   K   P
R:                 2+   +  +   2+   +   plantar flexion
L:                 2+    +  +  2+   +   flexion

Diagnosis: Pyrexia under evaluation.
               2D ECHO
                   USG ABDOMEN 
Rx:
inj. Pan 40mg × iv od
Inj. Zofer 4mg iv od
Inj. Neomol 1gm iv sos
Tab. Dolo 650mg × po× Tid.
Tab. Telmisartan-40mg.

Soap notes: 
S: 2 fever spikes
O/E:
Pt is lethargic.
AFebrile
Pr: 110bpm
Bp:  170/100mmhg
Spo2:  99@ RA
GRBS: 93mg/dl
RR: 20cpm.
RS: BAE+
CVS: S1 S2+
Cns: patient is lethargic
Pupils: NSRL
Power: Moving all limbs.
Tone: normal
Reflexes      B   T   S   A   K   P
R:                 2+   +  +   2+   +   plantar flexion
L:                 2+    +  +  2+   +   flexion

A: Viral Pyrexia with anemia under evaluation, AKI on CKD k/c/o Dm and HTN.
P:
inj. Pan 40mg × iv od
Inj. Zofer 4mg iv od
Inj. Neomol 1gm iv sos
Tab. Dolo 650mg × po× Tid.
Tab. Telmisartan-40mg



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