A 35 year old female with c/o of fever

 MEDICAL CASE

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed 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'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 comments in comment box are most welcomed.

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  


CASE DISCUSSION:

A 35year old female farmer by occupation came with complaints of fever,burning micturation,abdominal pain,lower back pain since 6 days.dry cough ,soar throat since yesterday.

HOPI:

Patient was apparently asymptomatic 6 months back and then developed b/l small joint pain for which she was treated in private hospital at miryalaguda and now came with complaints of fever which was associated with chills and rigor,evening rise of temperature and with burning micturation,associated with abdominal pain which was  diffuse and lower back pain and dry cough.

No cold

No h/o bleeding manifestations, no h/o melena, no h/o rash.

PAST HISTORY:

not a K/C/O DM,HTN,TB,EPILEPSY,ASTHMA.

PERSONAL HISTORY:

She is Married and farmer by occupation.

She consumes 

Mixed diet 

sleep is adequate 

Appetite normal

bowel and bladder movements are regular

no addictions

FAMILY HISTORY: no similar complaints in the family.

DAILY ROUTINE: 6 months back (when pt was normal) she used to getup at 5am and do house chores and then after having her breakfast she used to go for work on farm from 10am to 5pm, she used to have her lunch there itself. After coming back from farm she used to do her chores and sleep by 9pm.

(After getting joint pains) Pt used to get up at 6am and stopped going to farm used to do some house chores and then used to take rest and sleep by 10pm.

CLINICAL IMAGES:






GENERAL EXAMINATION:

Patient is conscious , coherent and cooperative and well oriented to time place and person, 

Moderately built and moderately nourished.

VITALS:

BP: 100/50mmhg

PR: 78bpm

RR: 20cpm

Temp: 97.6f

GRBS: 102mg/dl - 8am

Spo2: 98%

SYSTEMIC EXAMINATION:

RS: BAE+ clear

CVS: s1,s2 no added sounds

P/A: not tender

CNS: NAD


PROVISIONAL DIAGNOSIS: Viral pyrexia under evaluation 


INVESTIGATIONS:

















TREATMENT:

1.IVF 10NS 10RL @ 100ml/hr

2.INJ.PAN 40mg/IV

3.TAB.DOLO 650mg/PO SOS

4.SYRP. CITRALCA 5ml

5. INJ.NEOMOL 1gm/IV/STAT

6.Monitor vitals every 4th hrly


Day 2

S: fever,burning micturation,abdominal pain,lower back pain since 6 days.dry cough ,soar throat since yesterday.

Presently fever +, generalised body pains.

O: pt is conscious, coherent,cooperative.

BP: 100/50mmhg

PR: 78bpm

RR: 20cpm

Temp: 97.6f

GRBS: 102mg/dl - 8am

Spo2: 98%

SYSTEMIC EXAMINATION:

RS: BAE+ clear

CVS: s1,s2 no added sounds

P/A: not tender

CNS: NAD

A:Viral pyrexia under evaluation 

P:

1.IVF 10NS 10RL @ 100ml/hr

2.INJ.PAN 40mg/IV

3.TAB.DOLO 650mg/PO SOS

4.SYRP. CITRALCA 5ml

5. INJ.NEOMOL 1gm/IV/STAT

6.Monitor vitals every 4th hrly




Day 3

S: fever,burning micturation,abdominal pain,lower back pain since 6 days.dry cough ,soar throat since yesterday.

Presently no fever spike , pain abdomen .

O: pt is conscious, coherent,cooperative.

BP: 100/90mmhg

PR: 90bpm

RR: 20cpm

Temp: 96.6f

GRBS: 84mg/dl - 8am

Spo2: 97%

SYSTEMIC EXAMINATION:

RS: BAE+ clear

CVS: s1,s2 no added sounds

P/A: not tender

CNS: NAD

A:Viral pyrexia under evaluation 

P:

1.IVF 10NS 10RL @ 100ml/hr

2.INJ.PAN 40mg/IV

3.TAB.DOLO 650mg/PO/TID

4.SYRP. CITRALCA 5ml

5. INJ.NEOMOL 1gm/IV/STAT

6.Inj.Optineuron 1amp in 100ml @ 50ml/hr

7.Syrp.Potklor 15ml in 100ml water po/TID

8.Tab.Cetrizine 10mg/PO/OD 

9.SYRP.CITRALICA 15ml with 1/2 glass water 

10. Monitor vitals 4th hrly





Day 4

S: fever,burning micturation,abdominal pain,lower back pain since 6 days.dry cough ,soar throat since yesterday.

Presently fever spike , pain abdomen .

O: pt is conscious, coherent,cooperative.

BP: 110/80mmhg

PR: 88bpm

RR: 28cpm

Temp: 100.7f

GRBS: 102mg/dl - 8am

Spo2: 98%

SYSTEMIC EXAMINATION:

RS: BAE+ clear

CVS: s1,s2 no added sounds

P/A: not tender

CNS: NAD

A:Viral pyrexia under evaluation 

P:

1.IVF 10NS 10RL @ 100ml/hr

2.INJ.PAN 40mg/IV

3.TAB.DOLO 650mg/PO/TID

4.SYRP. CITRALCA 5ml

5. INJ.NEOMOL 1gm/IV/STAT

6.Inj.Optineuron 1amp in 100ml @ 50ml/hr

8.Tab.Cetrizine 10mg/PO/OD 

9.SYRP.CITRALICA 15ml with 1/2 glass water 

10. Syrp.Potklor 15ml in 100ml water po/TID










Day 5

S:
Presently pain abdomen in the R lumbar and inguinal region.

O: pt is conscious, coherent,cooperative.
BP: 90/60mmhg
PR: 88bpm
RR: 22cpm
Temp: 97.2f
Spo2: 98%

SYSTEMIC EXAMINATION:
RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: Tenderness in the right lumbar and inguinal region 
CNS: NAD

A:Viral pyrexia under evaluation 

P:
1.IVF 10NS 10RL @ 100ml/hr
2.INJ.PAN 40mg/IV
3.TAB.DOLO 650mg/PO SOS
4.SYRP. CITRALCA 5ml
5. INJ.NEOMOL 1gm/IV/STAT
6.Inj.Optineuron 1amp in 100ml @ 50ml/hr
8.Tab.Cetrizine 10mg/PO/OD 
9.SYRP.CITRALICA 15ml with 1/2 glass water 
10. Monitor vitals 4th hrly

Day 6

S:
Presently pain abdomen subsided , generalised weakness +

O: pt is conscious, coherent,cooperative.
BP: 90/60mmhg
PR: 80bpm
RR: 20cpm
Temp: 98.2f
Spo2: 98%

SYSTEMIC EXAMINATION:
RS: BAE+ clear
CVS: s1,s2 no added sounds
P/A: soft , non tender  
CNS: NAD

A:pyrexia with LRTI

P:
IVF 10NS 10RL @ 100ml/hr
TAB.DOLO 650mg/PO SOS
Inj.Optineuron 1amp in 100ml @ 50ml/hr
Syrp.Grillinctus 15ml TID
Tab.Cetrizine 10mg/PO/OD 
TAB.zincovit po/od
Monitor vitals 4th hrly

DISCHARGED ON 07/09/2022 as the symptoms subsided.
ADVICE AT DISCHARGE:
1.Tab.Dolo 650mg PO SOS
2.Tab.MVT OD for 10 days
3.Plenty of fluids to be taken

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