35yr old female with c/o fever

 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.

CHIEF COMPLAINTS 

A 35year old female farmer by occupation came with C/o fever since 6 days 

        • Burning micturition since 6 days

       • Abdominal pain,lower abdominal and back             pain since 6 days.

       • Dry cough ,sore throat 3 days back.

       • B/l pedal edema

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 6 months back and then developed b/l small joint pain( meta carpophalyngeal for which she was treated in private hospital at miryalaguda and now came with complaints of fever ( high grade intermittent in nature)which was associated  with chills and rigor,evening rise of temperature and with burning micturition, associated with abdominal pain which was  diffuse and lower back pain and cough which is non productive.

No cold

No h/o bleeding manifestations, no h/o melena, no h/o rash.





PAST HISTORY

Not a K/C/O DM,HTN,TB,EPILEPSY,ASTHMA.

PERSONAL HISTORY:

She is Married and farmer by occupation.

She consumes mixed diet 

sleep is adequate 

Appetite normal

bowel and bladder movements are regular

no addictions

FAMILY HISTORY

no similar complaints in the family.

GENERAL EXAMINATION 

Patient is conscious,coherent ,cooperative well oriented to time ,place and person
She is moderately built and nourished 

Vitals at time of admission:

BP: 100/70mmhg
PR:84 bpm 
Temp:97.2°F
RR : 20 cpm
NO pallor, icterus , clubbing ,cyanosis, generalized lympadenopathy ,pedal edema+
SpO2 -98%
Grbs -97mg/dl

SYSTEMIC EXAMINATION:

PER ABDOMEN : 
shape of abomen is scaphoid,no scars,
sinuses,no hernial orifices,no 
tenderness on palpation , no organomegaly,
CNS : no focal neurological deficits
CVS : S1 ,S2 heart sounds heard ,no murmurs
RS: Normal vesicular breath sounds,no adventitious sounds, Bilateral air entry present.

PROVISIONAL DIAGNOSIS 
Viral pyrexia under evaluation.

FEVER CHART


ECG 


INVESTIGATIONS 









Ultrasound  


2D echo

IMAGING 



URINE CULTURE 


TREATMENT

1.IVF 10NS 10RL @ 100ml/hr

2.INJ.PAN 40mg/IV

3.TAB.DOLO 650mg/PO SOS

4.SYRP. CITRALCA 5ml

5. INJ.NEOMOL 1gm/IV/STAT

6.Monitor vitals every 4th hrly.


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