25/F WITH FEVER
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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.
25Y/F came to OPD on 28.7.2021 with complaints of
•FEVER SINCE 6 DAYS
• HEADACHE SINCE 6 DAYS
•LOSS OF APPETITE SINCE 6 DAYS.
HOPI:-
Patient was apparently asymptomatic 1 week before 28.7.2021 when she started developing fever which is high grade, intermittent, associated with chills and rigors.
Headache- frontal and temporal regoins s
Loss os appetite and generalised weakness.
No h/o nausea, vomitings, loose stools.
PAST HISTORY:-
No h/o similar complaints in the recent past.
Not a k/c/o of HTN,DM, ASTHMA, EPILEPSY, TB, CAD.
FAMILY HISTORY:-
Both mother and father of the patient are hypertensive and diabetic.
ON EXAMINATION:-
Patient is conscious, coherent and cooperative.
No signs of pallor,icteurs, clubbing, Lymphadenopathy and edema.
Vitals:-
PR=60bpm
RR= 12 cpm
BP= 100/60mmhg (supine)
60/40mmhg (standing)
Temparature =99.4F
CVS- S1,S2 +
RS- BAE+, NVBS heard
P/A -Soft, NT
CNS- NAD
PROVISIONAL DIAGNOSIS:- ?VIRAL PYREXIA
INVESTIGATIONS:-
28-7-2021
BGT- A+
BLOOD UREA=29mg/dl
SERUM CREATININE =1mg/dl
SERUM ELECTROLYTES:- Na+=127mEq/L,
K+= 4mEq/L, Cl- =90mEq/L
SEROLOGY - negative
NS1- negative
29-7-2021
APTT=31sec
PT=15 sec
INR= 1.1
30-7-2021
31-7-2021
1-8-2021
ESR=35
CRP=2.4 (positive)
2-8-2021
3-8-2021
TREATMENT:-
28-7-2021
IVF NS,RL @ 150ml/hr
INJ. PANTOP 40mg IV/OD
INJ. ZOFER 4mg IV/STAT
INJ. NEOMOL 1g IV/SOS
TAB. PCM 500mg PO/TID
SYP. ASCORIL 5ml PO/TID
BP MONITORING HRLY
CHECK FOR POSTURAL HYPOTENSION
TEMP CHARTING
I/O CHARTING
29-7-2021
IVF NS,RL @ 150ml/hr
INJ. PANTOP 40mg IV/OD
INJ. ZOFER 4mg IV/STAT
INJ. NEOMOL 1g IV/SOS
INJ. OPTINEURON 1 amp in 100ml NS IV/OD
TAB. PCM 500mg PO/TID
SYP. ASCORIL 5ml PO/TID
BP MONITORING HRLY
CHECK FOR POSTURAL HYPOTENSION
TEMP CHARTING
I/O CHARTING
INJ. FALCIGO 20mg/IV /STAT
30-7-2021
IVF NS,RL @ 150ml/hr
INJ. PANTOP 40mg IV/OD
INJ. ZOFER 4mg IV/STAT
INJ. NEOMOL 1g IV/SOS
INJ. OPTINEURON 1 amp in 100ml NS IV/OD
TAB. PCM 500mg PO/TID
SYP. ASCORIL 5ml PO/TID
BP MONITORING HRLY
CHECK FOR POSTURAL HYPOTENSION
TEMP CHARTING
I/O CHARTING
INJ. FALCIGO 20mg/IV @11am
31-7-2021
IVF NS,RL @ 150ml/hr
INJ. PANTOP 40mg IV/OD
INJ. ZOFER 4mg IV/STAT
INJ. NEOMOL 1g IV/SOS
INJ. OPTINEURON 1 amp in 100ml NS IV/OD
TAB. PCM 500mg PO/TID
SYP. ASCORIL 5ml PO/TID
BP MONITORING HRLY
CHECK FOR POSTURAL HYPOTENSION
TEMP CHARTING
I/O CHARTING
INJ. FALCIGO 20mg/IV @11am
1-8-2021
IVF NS,RL @ 150ml/hr
INJ. PANTOP 40mg IV/OD
INJ. ZOFER 4mg IV/STAT
INJ. NEOMOL 500ml IV/4th hrly
INJ. OPTINEURON 1 amp in 100ml NS IV/OD
TAB. PCM 500mg PO/TID
TAB. DOXYCYCLINE 100mg PO/BD
INJ. CEFTRIAXONE 1g IV/TID
BP MONITORING HRLY
CHECK FOR POSTURAL HYPOTENSION
TEMP CHARTING
I/O CHARTING
2-8-2021
IVF NS,RL @ 150ml/hr
INJ. PANTOP 40mg IV/OD
INJ. ZOFER 4mg IV/STAT
INJ. NEOMOL 500ml IV/4th hrly
INJ. OPTINEURON 1 amp in 100ml NS IV/OD
TAB. PCM 500mg PO/TID
TAB. DOXYCYCLINE 100mg PO/BD
INJ. CEFTRIAXONE 1g IV/TID
BP MONITORING HRLY
CHECK FOR POSTURAL HYPOTENSION
TEMP CHARTING
I/O CHARTING
3-8-2021
IVF NS,RL @ 150ml/hr
INJ. PANTOP 40mg IV/OD
INJ. ZOFER 4mg IV/STAT
TAB. PCM 650mg PO/SOS
TAB. DOXYCYCLINE 100mg PO/BD
INJ. CEFTRIAXONE 1g IV/TID
BP MONITORING HRLY
CHECK FOR POSTURAL HYPOTENSION
TEMP CHARTING
I/O CHARTING
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