40 year female with fever

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CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever

PRESENTING COMPLAINTS:

C/O Fever since 4 days.

C/O Nausea since 4 days.

C/O loose stools for a day.

C/O Generalized weakness for a day.

HOPI:

A 40 year female, Agriculturer by occupation clinically presented to the OPD with complaints of low grade intermittent fever not associated with chills and rigors; for which she sought for consultation at a local hospital, she was started on Intravenous fluid therapy for having a low blood pressure and discharged. History of scanty whitish productive cough, non blood stained since 4 days. History of nausea since 4 days leading to decreased food intake. History of 4-5 episodes of loose stools, watery in consistency, non foul smelling, non mucoid and non blood stained and not associated with abdominal pain for a day. Patient sought for consultation and now admitted for further evaluation and management.

PAST ILLNESS:

No Comorbidities.

SURGICAL HISTORY:

S/P - Total abdominal hysterectomy with B/L salpingo-oophorectomy under GA in 2012 i/v/o Multiple Fibroids.

PERSONAL HISTORY:

Moderately built and nourished.

Appetite normal.

Sleep adequate.

Regular bladder and bowel movements.

Allergic to Dust.

FAMILY HISTORY:

No similar compalaints in family members.

No Comorbidities.

MENSTRUAL HISTORY:

Age at Menarche: 16 yrs.

Post Hysterectomy status.

OBSTETRIC HISTORY:

Age at Marriage: 14 yrs.

Age at 1st child birth: 19 yrs.

G²P² 

1st pregnancy: Spontaneous conception, Caesarean section, male child.

2nd pregnancy: Spontaneous conception, Caesarean section, female child.

GENERAL EXAMINATION:

Patient was conscious and coherent.

Afebrile, Temp 98.4°F.

PR: 94bpm; RR: 18cpm; BP: 110/70mmHg; SpO2: 98%@RA; GRBS : 115 mg/dl.

CVS: S1,S2+; R/S: BAE+, Clear; P/A: Soft, Non tender, BS+; CNS: NFND.

COURSE IN THE HOSPITAL:

A 40 year female presented with above mentioned complaints. After initial workup, patient was shifted to AMC, and she was started on supportive therapy. Laboratory investigations showed Hb 15.1gm%; TLC 5,600 cells cu.mm; platelet count 240000 cells cu.mm. Her RBS was 114 gm/dl, Urea 22 mg/dl and serum creatinine 0.8 mg/dl. PT 16 sec; APTT 32 sec and INR 1.11. Viral serological markers and Dengue serology was negative. CUE showed normal study with 2-4 pus cells. She had no bleeding manifestations, no postural drop. USG Abdomen was done which showed the Grade I Fatty liver and normal renal size and echotexture with CMD maintained and PCS  was normal. During the stay in the hospital she was treated with oral Antipyretic, antacid and other supportive medications. She was hemodynamically stable and being discharged ina stable condition.

ECG AT PRESENTATION:

CHEST X RAY PA VIEW:

FEVER CHART:

INVESTIGATIONS CHART:

USG ABDOMEN:

DIAGNOSIS:

VIRAL PYREXIA

TREATMENT:

1. PLENTY OF ORAL FLUIDS.

2. INJ. NEOMOL 100ML /IV/ SOS ( IF TEMP>101°F)

3. TAB. DOLO 650MG /PO/ SOS (IF TEMP > 98.6°F)

4. SYP. ASCORYL D 15ml/PO/TID.

5. WATCH FOR BLEEDING MANIFESTATIONS.

6. TEMP CHARTING AND VITAL MONITORING.

DISCHARGE TREATMENT:

1. PLENTY OF ORAL FLUIDS.

2. TAB. DOLO 650mg /PO / SOS ( IF HAVING FEVER).

3. SYP. ASCORYL D 15 ML/PO/ TID FOR 5 DAYS.

4. TAB. MVT /PO/ OD FOR 15 DAYS.