33 year old female patient complains of fever

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 input 

This Eblog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

CHIEF COMPLAINT:-

A 33 years old female presented to OPD with a complaint of high grade fever with chills since 3 days.

History of present illness:

Patient was apparently asymptomatic 3 days ago and developed fever with chills which got aggrevated yesterday and had two episodes  of vomiting yesterday after having meals with generalized body pains and headche.

History of past illness:

No h/o rash,SOB,Cough

No h/o lip swelling

No h/o outside, allergies and food exposure

No h/o DM, HTN,TB, CVA, CAD,Asthma, Epilepsy.

Personal history:

Patient has normal appetite, takes mixed diet, regular bowel and bladder movements,adequate sleep and no addictions.

Family history:-

There are no similar complaints in the family members 

Drug history:

Not allergic to known drugs.

General examination:

Patient was conscious, coherent and cooperative.

Moderate built and adequately nourished.

No signs of pallor, cyanosis, clubbing, icterus,oedema of feet and hand, lymphadenopathy.

Vitals :-

Temperature:103F

Pulse rate:92 BPM

Respiratory rate:18CPM

B.P.:110/80

GRBS:135mg%

SPO2 at room air:98%

SYSTEMIC EXAMINATION:-

CVS:-

-Chest wall is bilaterally symmetrical

-No visible pulsations ,engorged veins,scars,sinuses 

-JVP is normal 

-S1 S2 heard

RESPIRATORY SYSTEM:-

-Bilateral air entry is normal

-Position of trachea is central 

-Vesicular breath sounds heard 

ABDOMEN:-

-Bowel sounds heard 

-No tenderness

-No palpable mass

-Normal hernial orifices 

-No free fluid

-No bruits 

-Liver and spleen are not palpable 

CNS:-

-Patient is conscious

-Speech -Normal 

-No neck stiffness 

Investigations:

On 22/11/2021

Hemogram:

HB:12.7

TLC:4300

PLT:2.48

PCV:37.1

RBC:4.88

Serum creatinine:0.8

Serum Na+:140

Serum K+:3.9

Serum Cl-:96

Malarial parasite:-ve

Rapid dengue:-ve

23/11/2021

Hb-14gm/dl

Total count  -8500 cells /cumm

PLT-1.4 lakh/mm3

Fever chart :-.                                        

ECG:-

 

PROVISIONAL DIAGNOSIS:-

?Viral pyrexia 

Treatment:

1.IVF

2.Dolo 650mg BID every 6th hourly

3.Inj pantop IV UD

4.Inj neomal iv 

5. Pleaty of oral fluids

6.temp chart plotting every 4th hourly

7.GRBS every 12 hourly

8.B.P. chart every 4th hourly

9.inj zofer iv bd