21 years old female patient with fever and headache since 3 days
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Name: Manvitha (intern)
A 21 year old female patient came to causality with chief complaints of
fever since 3 days
headache since 3 days and
body pains since 3 days
HOPI
Patient was apparently asymptomatic 3 days back then she developed fever of high grade continuous with chills and rigor and headache (diffuse) and
body pain relieving on medication but recurring no diurnal variation cold negative no cough no vomitings no burning micturition no abdominal pain no rash no sore throat
Past history
Patient is not a known case of HTN, DM , CAD, CVA, TB Epilepsy
Personal history
occupation student ,
appetite normal
diet non veg
bowel and bladder movements normal
no addictions
family history insignificant
Past surgical history :
No past surgical history
Menstural history
age of menarche 13 years
regular 5/30 day cycle
General examination
patient is conscious cooperative coherent well oriented to time place person
no pallor , icterus, cyanosis, clubbing , lymphadenopathy, edema
Vitals
temperature : 101.8
PR: 95
RR:16cpm
BP 110/80mmhg
spo2: 98 at room air
GRBS: 133
Systemic examination
CVS S1S2 heard no cardiac murmurs heard
RS NAD NVBS heard
P/A Soft and non tender scaphoid abdomen
CNS : NAD
Investigations
USG : no sonological abnormalities
Provisional diagnosis : Pyrexia under evaluation
Treatment
IVF 1 unit NS AND RL @ 75ml/hr
INJ NEOMOL 1g/iv/SOS
TAB DOLO 650mg /PO/BD
TEPID SPONGING
TEMP, GRBS, RR, PR monitoring
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