AMC-20 YEAR OLD FEMALE

 

20 YEAR OLD FEMALE WITH FEVER AND BODYPAINS

September 19,2022


 "This is an online E log book 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 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 inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box

20 year old female came to the general medicine OPD on 19/09/2022 with cheif complaints of

-fever(high grade) since 4 days

-body pains since 4 days

-H/O 2 episodes of vomitings 2 days back

-abdominal pain in epigastric region since today morning



HOPI-

patient was apparently asymptomatic till 4 days back then she developped fever(high grade) which was relieved on medication and use to revert back.Patient had developped body pains 4 days back.2days back patient had 2 episodes of vomitings.After 3 days patient had developped abdominal pain in epigastric region


PAST HISTORY-

K/C/O- Hypothyroidism since 7 years and on THYRONORM 25mcg since 7years

Not K/C/O-HTN/DM/CVA/CAD/EPILEPSY/TB/ASTHMA


PERSONAL HISTORY-

Appetite-normal

Diet-mixed

Bowel and bladder movements-regular

Sleep-adequate

Habits-no history of alcohol intake and smoking


FAMILY HISTORY-

No similar compliants are present in family members


GENERAL EXAMINATION-

Pallor-absent

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Edema-absent

VITALS-

BP-90/70 mmHg

PR-93 bpm

TEMP-97.5F

SPO2-99% at RA

GRBS-146 mg/dl

SYSTEMIC EXAMINATION-

=>CVS-S1S2+,no thrills,no murmurs

=>R/S-BAE+

       position of trachea-central,

        no wheeze

        no dyspnoea

=>P/A-

shape of abdomen-obese

Tenderness is present in epigastric region

No palpable mass 

No free fluid
Hernial orifices-normal
Liver-not palpable
Spleen-not palpable
=>CNS-patient is conscious,coherent and cooperative
Speech-normal
No signs of meningeal irritation
Cranial nerves-intact
NFND
PROVISIONAL DIAGNOSIS
VIRAL PYREXIA WITH THROMBOCYTOPENIA

INVESTIGATIONS
19/09/2022


















TREATMENT
1)IV FLUIDS-NS,RL @75ML/HR
2)TAB.DOLO 650MG PO/TID
3)TAB.PANTOP 40MG PO/OD
4)TAB.THYRONORM 75MCG PO/OD
5)INJ.OPTINEURON IN 100ML NS OVER 30 MINUTES
6)INJ.ZOFER 4MG IV/SOS







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