49 year female with fever
A Rishi koundinya
Batch - 2017
DR. RAKESH BISWAS (HOD).
DR. SRI HARSHA (SR).
DR. SHAILESH (PGY3).
DR. KRANTHI (PGY1).
This is an online E logbook 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 a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs
CHIEF COMPLAINTS:
Fever since 15 days.
Abdominal discomfort since 15 days.
Generalized weakness since 15 days.
Decreased appetite since 15 days.
HOPI:
A 49 year female presented to the OPD with complaints of high grade Intermittent fever associated with chills, malaise and decreased appetite. Fever was relieved on taking medication. History of abdominal discomfort as tightness since 15 days not associated with vomiting. History of nausea associated with decreased appetite. No history of headache, retro orbital pain, cold, cough, chest pain, SOB, PND, Orthopnea, burning micturition.
she sought for consultation at local RMP and took medication (Antipyretic and Antibiotic), fever was releived upon taking medication associated with excessive sweating. She got fever spike on the same day, she sought for consultation at local hospital; she was treated with IV Antipyretic, Antibiotic and Analgesic medication daily on opd basis for 4 days. She stayed at home for the rest of 10 days and received treatment with Oral and IV Antipyretics, Antibiotics. Now admitted for further evaluation and management.
PAST ILLNESS:
No Comorbidities.
SURGICAL HISTORY:
S/P - Tubectomy under LA in 1997.
S/P - Hysterectomy with B/L salpingo-oophorectomy under GA in 2014 i/v/o massive Uterine fibroid.
PERSONAL HISTORY:
Moderately built and nourished.
Sleep decreased.
Appetite lost.
Bowel and bladder are regular.
No addictions.
GENERAL EXAMINATION:
Patient was conscious and coherent.
No pallor, Icterus, cyanosis clubbing, lymphadenopathy and edema.
Neck rigidity.
Febrile.
VITALS:
PR: 92bpm; BP:110/80mmHg; RR: 22; SpO2: 98%@RA; Temp: 101°F; GRBS: 121mg/dl.
CVS: S1,S2+, No added sounds;
R/S: BAE+, Clear;
P/A: Soft, Upper abdominal tenderness, BS+;
CNS: HMF intact; GCS 15/15; B/L Upper and lower limb time and power are normal; Kernig's and Brudzinski sign -ve.
Investigation chart
TREATMENT:
1. IVF NS/RL @75ml/hr.
2. INJ. NEOMOL 100ml / IV / SOS ( IF TEMP >=102°F)
3. INJ. PAN 40mg / IV / OD.
4. INJ. ZOFER 4mg / IV / TID.
5. TAB. DOLO 650mg/ PO / QID.
6. VITAL MONITORING.
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