A 25 year old female with high grade fever

 

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A 25 year old female a lactating mother with a 6months old baby came with a Che if complaints of  high grade fever since 3 days 

History of presenting illness 

The patient was apparently asymptomatic 5 days back then she developed fever which was incesidious  onset and gradually progressed to high grade 2 days back , it was continuous and decreased temporarily on medication but not touching to base line  . 

there is history of loose stool since 5 days 

History of vomiting since 2 days non bilious , non projectile 2- 3 episodes per day

History of headache neck pains along with fever 

And generalized body pains and had burning miturition and decreased appetite 

Past history 

No history of similar complaints in the past 

No history if Hypertension , diabetes , 

Epilepsy, TB , asthma 

H/o LSCS surgery 6 months back 

Personal history 

Diet mixed 

Appetite decreased

Sleep adequate

Bowls habits loose stools since 5 days 

Bladder : burning micturition since 5 days 

Addictions  no 

Married - 3 years ago 

She was a house wife  , lactating mother  house wife does the house chores and look after her children 1st boy 22 months old and 2nd girl 6 months old . her husband was a lordy driver by occupation 

Family history

Not significant

General physical examination

Patient was conscious coherent cooperative moderately built and nourished well oriented to time , place and person.

Pallor : present

Icterus : absent 

Cyanosis : absent

Clubbing : absent

Lympadenopathy : absent

Edema : absent 

Neck rigidity : present ( pain decreased this evening)

 

Vitals :

Systemic examination 

CVS : S1 S2 heard no murmurs 

RS : BAE + trachea central , no stridor

CNS : NAD 

P/A : Lscs scar is present 

Rash marks over abdomen  is seen 

( rash occurs in the 1 st month after delivery according to patient their families has a tradition that they apply the leaves juice of been etc all over the body on scar etc ) 

Investigations

HB : 9.9 *

TLC : 4500

N/L/E/M : 50/41*/02/07

PLATELETS : 2.42

LFT 

TB:0.79

DB: 0.24*

AST: 61*

ALT: 52

ALP:177

TP:6.6

Alb:3.3

A/G:1.02

RBS : 92 mg/DL

NS1 Antigen : negative 

IgM : negative

IG G : negative 

Smear for M.P : negative

RFT 

Urea : 27

S.creatinine : 0.9

Uric acid : 3.6

Ca+2 : 9.4

PO4 : 4.5

Na+ : 139

K+ : 4.2

Cl- : 99

Provisional diagnosis

Viral pyrexia 

Or meningitis 

Treatment 

1. INJ CEFTRIAXONE 2mg IV BD

2. IVF NS / DNS @ 100ml/hr

3. INJ PAN 40mg/IV/OD

4.INJ.ZOFER 4mg/IV/TID

5.INJ.NEO 1mg/IV/SOS if temp>102°F

6.Tab.Solo 650mg PO/TID

7.OPTINEURON 1amp in 100ml NS I.V/OD

8.Temp. Monitoring 4th hourly

9.Monitor Vitals and inform SOS

10.Inj.Doxycycline 100mg I.V /BD