CASE HISTORY 3

 CASE HISTORY 3 :

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Date of admission - 11th September 2021

A 33 year old female patient came to the opd with  cheif complaint of :

High fever since 3 days

Lower back pain since 3 days

HISTORY OF PRESENT ILLNESS  : 

Patient was apparently asymptomatic 3 days back then developed high fever and with body pains mainly on the lower backache after the episodes of fever.which is generally radiating to the groin

Fever is sudden in onset , continuous, and relieved by taking medications .when medication is stopped fever is seen again

And the fever is associated with rigors and sweating . And the sweating is generally present after taking medications.

Onset of body pains is sudden in onset seen initially in the loin region which is bilateral followed by headache which is diffuse.

 And then generalised body pains are seen which are dragging type and aggravated by walking. 

No history of cough, vomiting and diarrhea. 

No history of burning micturition

History of loss of appetite is seen

PAST HISTORY : 

There is a history of hysterotomy .

And no history of diabetes mellitus, hypertension, asthma,epilepsy.

PERSONAL HISTORY : 

Diet : mixed

Sleep : adequate

Bowel and bladder movements are normal 

Appetite is decreased.

There is no history of allergies to known drugs

Menstrual cycle is normal 

FAMILY HISTORY  : 

There are no similar complaints in the family members.

TREATMENT HISTORY  :

Patient took dolo - 650 for 3 days three times a day for fever and body pains before joining the hospital.

GENERAL EXAMINATION  : 

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

Moderately built and nourished

No cyanosis 

No clubbing

No icterus

No generalised lymphadenopathy are seen.

VITALS : 

Temperature : 100.7

Pulse rate : 74 bpm

Blood pressure  : 110 / 70 mmhg

Respiratory rate : 18 per min

Spo2 : 98 % in room air .

SYSTEMIC EXAMINATION:

Rs : BAE positive

Cvs :  S1 and S2 are heard

Pa : soft and non tender

Cns : no FND

PROVISIONAL DIAGNOSIS : 

viral pyrexia with athralgia

INVESTIGATIONS : 

               HEMOGRAM : 

Hemoglobin : 11.7

Total count : 8100

Neutrophils  : 37 

Lymphocytes : 23

Eosinophils : 2

Monocytes : 8

Basophils : 0

PCV : 35.5

MCV : 73.8

MCHC : 24.3

RBC : 4.18

Platelets : 2.75

Dengue Ns1 antigen - negative

           IgM - negative

            IgG - negative

ESR - 30 I.e CRP is Negative

Complete urine examination :

Albumin: positive

Sugar : nil

PC  3 - 4

Ec   2 - 3

RBC : nil

                              ECG

                 

                              ULTRASOUND

RFT : 

Serum creatinine : 0.9

Blood urea - 10

Serum electrolytes -

Na - 140

K - 4

Cl - 99

LFT : 

Tb : 0.63

Db : 0.20

AST : 17

ALT : 19

ALP : 191 

Albumin : 3.6

            

      TREATMENT  : 

1. IVF : NS , RL - 75 ml/hr

2. Inj. Neomol 100ml NS  IV / OD

3. Inj. Tremadol  1 AMP IN 100 ml  NS IV /  SOS

4. Inj. Pantop 40 mg IV/OD

5. Inj. Zofer 4 mg IV / SOS

6. Tab pcm 500 mg PO / TID

7. Tab ultracet 1/2 - 1/2 -1/2 - 1/2

8. Monitor vitals for every 4th hourly 

9. Temperature charting .