39year old female with fever and severe frontal headache

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog 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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 


Case
A 39 year old female patient who is an agricuktural laborer came to opd with chief complaints of
        fever since 8 days
        headache since 6 days
        
History of presenting illness :
A 39 year female patient came casuality with complaints of high grade fever which was  intermittent associated with chills and rigors, and severe frontal headache since 10 days 
 She went to a local doctor 9 days back where she got some medication and discharged , after 2 days her fever and head ache are not subsiding so she went to a local hospital and treated in the view of typhoid but fever is not subsiding , she is having generalized weakness in this course of stay in local hospital. she was only on liquid diet during hospital stay. 3 days back she had an episode of loose stools, watery in consistency, non blood stained which was resolved on having medication and had shortness of breath .
She is having nausea 2 days back which was resolved by yesterday


Past history
No h/o diabetes, hypertension , TB, epilepsy , asthma etc

Personal history
Diet : mixed 
Appetite : decreased 
Bowel and bladder regular 
No allergies 
No addictions

MENSTRUAL HISTORY
Age of menarche: 15 yrs 
5/28 cycle

MARITAL HISTORY
Age of marriage : 17 yrs
1 st child : male child 
Delivered by normal vaginal delivery 
Age 21 yrs
2 nd child : female child 
Delivered by normal vaginal delivery
Age 19 yrs

ENVIRONMENTAL HISTORY
 H/o fevers in her locality




General physical examination 
Patient was conscious coherent Cooperative moderately built and nourished well oriented to time place and person
No pallor icterus cyanosis clubbing and lymphadenopathy 
Edema was present 
Vitals 
Temperature 98 .6° F
PR : 86 bpm
Bp :  90/70 
RR : 20 cpm
Systemic examination
CVS : S1,S2 heard 
RS : bilateral air entry present 
On percussion resonant sound is decreased on left upper lobe
Decreased breath sounds are heard on left upper lobe 
Per abdomen  : umbilicus is central no scars and sinuses 
On palpation : tenderness is present in epigastric area
CNS 
No focal neurological deficits 

PROVISIONAL DIAGNISIS 
viral pyrexia 
Investigations
                Hemogram ( 7/09/2022) 



                   8/08/2022

            Hemogram (9/07/2022)

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

Comments

Post a Comment

Popular posts from this blog

A 43 year old male came with complaints of abdominal distension since 3 days complaints of bilateral pedal edemas in 3 days

Image
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog 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 The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.  CO...
Read more

INTERSHIP IN MEDICINE AND PROCEDURE PERFORMED

Image
I am M. SREEJA an intern in department of General Medicine posted from October 1 to November 30    From October 1 to 15,  I was posted in periferals  1st-5 th of October ICU On the first day of Medicine posting I was posted in the ICU. All I did was monitor the patients who were in a critical state. It was the most important part of patient care and I was making sure everything was as good as can be. In the afternoon at lunch a nurse and an attender came rushing in informing me of a patient in the CKD ward who was unresponsive. Immediately I rushed into fight mode, called for help and shifted her to the ICU, I proceeded with chest compressions with guidance of my PGs, for 30 minutes. We intubated her on time. Sadly we couldn't revive her. She was a day care patient who has completed her dialysis and was about to go back home. One minute the patient was fine and the next minute she was gone. It was an awakening of what my role was for the next two months.  The se...
Read more

20 year old female with facial puffiness and fever since 10 days ( OSCE )

Image
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog 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 The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.  CO...
Read more