A 40years female with chief complaint of fever, headache,body pain since 10 days.
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 WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT
CHEIF COMPLAINTS:-
C/O fever since 10days
C/O headache since 10days
C/O body pains since 10days
C/O cough since 10days.
HISTORY OF PRESENT ILLNESS :-
Patient was asymptomatic 10days back and then she developed fever which is high grade, associated with chills and rigors.
Dry cough since 10days.
Neckpain and headache which is diffuse in nature since 10days.
Decreased appetite and Burning micturition since 4days.
HISTORY OF PAST ILLNESS :-
N/K/C/O diabetes, Hypertension, Tuberculosis, epilepsy, Asthma, CHD.
TREATMENT HISTORY:-
No previous treatment history.
PERSONAL HISTORY:-
Married
Occupation-farmer
Appetite-normal
Diet-nonvegeterian
Bowels- regular
Micturition- normal
Known allergies- no
No known habits like alcohol drinking, smoking
FAMILY HISTORY:-
No significant family history
GENERAL EXAMINATION:-
no pallor, cyanosis, icterus, lymphadenopathy, clubbing of fingers or toes, Oedema of feet, malnutrition, dehydration.
VITALS:-
Temp- 96.6 c
Pr- 88/ min
Rr-16/ min
Bp-110/70 mm /Hg
Spo2- 99%
GRBS-106 mg%
SYSTEMIC EXAMINATION:-
a)CVS - S1 S2 Positive
b)Respiratory system -BAE Positive
c)Abdomen
Shape- scaphoid
No Tenderness and palpable mass
Bruit-yes
Liver and spleen are not palpable
Bowel sounds- yes
d)CNS
conscious
Speech- normal
Signs of meningeal irritation like neck
Stiffness, kerning 's sign- no
Cranial system, motor system, sensory
system- normal.
no cerebral signs
INVESTIGATIONS:-
DIAGNOSIS:-
viral pyrexia
TREATMENT:-
IV Fluids @75ml per hour
Inj .CEFTRIAXONE- 1gm/IV/BD
Tab. DOXY- 100mg/PO/BD
Inj. ZOFER- 4mg/IV/SOS
Inj.PAN- 40mg/IV/OD
Tab.NAPROXEN 250mg/PO/TID
Advised to take plenty of oral Fluids
Watch for hypotensive symptoms
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