A 26yr old female with Fever and Giddiness

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December 15,2022

This is an online E-log book to discuss our patient de-identified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve those patient clinical problem with collective current best evidence based inputs.

This E-log also reflects my patient centered online learning portfolio.

Your valuable inputs on comment hbox 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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan.


Amc bed 2 admitted on 15/12/2022

A 26yr old female came to the casualty with complaints of
Fever since 4days
Headache since 4days
Giddiness since today afternoon

HISTORY OF PRESENT ILLNESS:

Patient was apparently alright 4days back then she had fever which is high grade , continuous,not associated with chills and rigors. It is releived by taking medication
It is associated with one episode of vomiting ,food particles as contents, non projectile ,non bilious.
Not associated with loose stools,burning micturition, cough and cold.
H/o headache since 4days.
She had giddiness since today morning and had loss of consciousness for 30mins but responded to stimuli

PAST HISTORY:

N/k/c/o DM ,HTN ,TB ,Asthma ,Epilepsy , CAD,CVD
No H/o blood transfusions 
H/o tubectomy done 6yrs back

PERSONAL HISTORY:

Diet : Mixed
Appetite :normal
Sleep : Adequate
Bowel and bladder movements :Regular
No allergies and no Addictions 

MENSTRUAL HISTORY:
Age at menarche-14yrs
Last menstrual period-8/12/2022

OBSTETRIC HISTORY:
Age at marraige-16yrs
3children
1st child-Girl (9yrs)
2nd child-Girl(7yrs)
3rd child-Boy(5yrs)

FAMILY HISTORY :

No significant family history.

GENERAL PHYSICAL EXAMINATION :

Patient is conscious, coherent, co-operative 
Patient is moderately built and is moderately nourished.
There is no pallor, icterus,cyanosis, clubbing, edema of feet and lymphadenopathy.







Vitals:
Temp-98.6F
PR:94bpm
RR:21cpm
BP:90/60mm Hg
Sp02 98@RA
GRBS-106gm/dl


SYSTEMIC EXAMINATION :

Cardiovascular System : S1, S2 heard, no murmurs

Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.Position of trachea central.

Central Nervous System : Conscious; Speech normal ; Motor and sensory system examination is normal, Gait is normal.

Per abdomen : soft, non tender. No organomegaly. 


INVESTIGATIONS :

On 15/12/22

  • Hemogram :

Hemoglobin : 12.2 g/dl

TLC : 3000

Neutrophils : 76%

Lymphocytes : 23%

Eosinophils : 00%

Basophils : 00%

PCV : 36.8

MCV : 89.8fl

MCH : 29.8pg

MCHC : 33.2%

RDW-CV : 12.1%

RDW-SD : 40.5fl

RBC count : 4.10millions/mm3

Platelet count : 1.5 lakhs/mm3

Smear : Normocytic normochromic blood picture with leucopenia


  • Complete urine examination 

Sugars-Nil

Albumin: +++

  • Dengue NS1 antigen: Negative 

  • RBS

  • Serology 




  • RFT
  • LFT

On 16/12/2022

  • LFT

  • RFT



  • USG Abdomen




PROVISIONAL DIAGNOSIS:

? VIRAL PYREXIA 


TREATMENT:

IV Fluids NS,RL@100ml/hr

INJ.PAN 40mg IV OD

INJ. Zofer 4mg IV SOS

Tab. PCM 650mg PO TID

INJ. NEOMOL 1gm IV SOS(if temp >101F)

Temperature monitoring hourly

 

16/11/22



S
Fever subsided complaining of giddiness

O
Vitals:
Temp-98.6F
Pr-94bpm
Rr-21cpm
Bp-90/60mm Hg
Sp02 98@RA
GRBS-106gm/dl

Cvs-s1,s2+
Rs- BAE+
P/A soft non tender
Cns-HMF intact

A
?viral Pyrexia

P
IV Fluids 
Inj. Neomol 1gm (if temp >101F)
Inj pan 40mg iv od
Ink.zofer 4mg iv sos
Tab pcm 650mg po tid

On 16/12/2022 at 6:40pm patient discharged  at request 





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