39 year female with fever

September 10,2022


Hi,I am Athram Divya Sri 3 rd semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio. 

                  CASE SHEET

CHIEF COMPLAINTS:

A 39 year old female patient who was agriculturer by occupation  came to OPD with the following symptoms :-
Fever since 8 days.
Generalized weakness for 6 days.
SOB since a day.
Loose stools for a day.

HISTORY OF PRESENT ILLNESS:

A 39 year female, Agriculturer by occupation clinically presented to casuality with complaints of High grade intermittent fever associated with chills and rigors, after a day she sought for consultation at a local RMP, she was started on IV fluids and sent home; On day 3 of fever she had severe frontal headache, for which she sought for consultation at local hospital and underwent treatment for typhoid fever for 5 days; during the course of hospital she still having high grade fever not associated with chills and rigors, generalized weakness for day 6 of fever; she was only on liquid diet during hospital stay. On day 7 of her fever she had an episode of loose stools, watery in consistency, non blood stained which was resolved on having medication and had shortness of breath of grade II NYHA for a day.


HISTORY OF PAST ILLNESS:


No Comorbidities.

HISTORY OF ALLERGY:

Allergic to Dust.

PERSONAL HISTORY:

Appetite : Normal
Diet : Mixed diet
Bowel movement : regular
Micturition : normal 
Sleep : Normal
Addictions : None

FAMILY HISTORY:

No similar compalaints in the family.

MENSTRUAL HISTORY:

Age at Menarche: 15 yrs.
5/28 day cycle.
Menses were started on the day of admission at 5pm.

OBSTETRIC HISTORY:

Age at Marriage: 17 yrs.
Age at 1st child birth : 19 yrs.
1st pregnancy: male child; spontaneous; Full term normal vaginal delivery + Episiotomy.
2nd pregnancy: female child; spontaneous; Full term normal vaginal delivery.

GENERAL EXAMINATION:

Patient was conscious and coherent.
Vitals:

Temp : 98.4°F.
PR: 84bpm
 BP: 110/80mmHg
RR: 19cpm
SpO2: 98%
GRBS: 97mg/dl.

INVESTIGATIONS:



DIAGNOSIS:
Viral pyrexia with Polyserositis


TREATMENT:

1. IVF NS/RL @125ML/HOUR 
2. INJ. NORAD @3ML/ HOUR.
3. INJ. NEOMOL 100ML /IV/SOS (IF TEMP>101°F)
4. TAB. MONTAIR LC /PO/HS.
5. TAB. DOLO 650MG/PO/QID.

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