A 24 YEAR OLD FEMALE WITH 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
19/09/2022
TREATMENT-
24 year old female patient came to the General Medicine OPD on 19/09/2022 with chief complaints of
-fever(high grade)since 9 days
-burning micturition since 9 days no C/O decreased urine output
-nausea and vomiting since 9 days(2 episodes per day)
-headache (diffuse type) associated with neckpain since 9 days
-body pains since 9 days
-rashes on face 4 days back
-dry cough (intermittent)
HOPI-
Patient was apparently asymptomatic 9 days back then she developped fever(high grade) associated with chills and rigors(more during night) and relieved on medication and reverts back.Then she developped nausea and vomitings(2 episodes per day) and she also developped headache(diffuse type) and associated with neck pain and patient also have bodypains since 9 days.She even developped dry cough(intermittent in nature) from 9 days
PAST HISTORY-
Tested dengue-igM-+ve on 14/09/2022
Not a K/C/O-DM,HTN,EPILEPSY,TB,ASTHMA,CVA,CAD
PERSONAL HOSTORY-
Sleep-adequate
Appetite-normal
Diet-mixed
Bowl and bladder movements-regular
Addictions-no history of alcohol intake and smoking
FAMILY HISTORY-
No similar complaints were present in family members
GENERAL EXAMINATION-
Pallor-absent
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Edema-absent
VITALS-
BP-100/60 mmHg
PR-132bpm
TEMP-102.2F
GRBS-154 mg/dl
SYSTEMIC EXAMINATION-
CVS-S1S2+,no thrills,no murmurs
R/S-BAE+
No dyspnoea
Postion of trachea-central
NVBS heard
No adventitious sounds heard
P/A-
Shape of the abdomen-scaphoid
Tenderness-present in right lumbar region
No palpable mass felt
Hernial orifices-normal
Free fluid-absent
Liver-not palpable
Spleen-palpable
Bowel sounds-heard
CNS-
Patient is conscious, coherent and cooperative
Speech- normal
No signs of meningeal irritation
Cranial nerves-intact
NFND
PROVISIONAL DIAGNOSIS-
VIRAL PYREXIA WITH DENGUE IgM POSITIVE WITH UTI?
INVESTIGATIONS-
19/09/2022-
20/09/2022
Fever chart(20/09/2022)
1)TAB.PANTOP 40MG PO/OD
2)TAB.DOLO 650 MG PO/QID
3)IVF-NS,RL @100 ML/HR
4)INJ.ZOFER 4MG IV/TID
5)INJ.NEOMOL IF TEMP >101°F
6)INJ.OPTINEURON IN 100ML NS OVER 30 MINS IV/OD
Comments
Post a Comment