34YEARS OLD FEMALE WITH FEVER

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This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

*CASE:

34 years female, from nalgonda ,agriculturer by occupation came to OPD with fever since 6 days.

HOPI:

Patient is apparently asymptomatic 3 days back then she developed fever 3 days ago which is raising in the evening times and reliving by medication. And associated with the frontal headache and neck pain . So she went to local clinic there they gave paracetamol,she took that tablets but again temperature is raising in the evenings  , so she came to our OPD.

History of burps after taking solid and liquid foods since 3 days

 No history of vomiting, diarrhoea,abdominal pain ,joint pains,burning micturation,ear pain.

No history of cold ,cough.

Daily routine:

She wakes up at 6 am and does her morning routine and eats breakfast at 9 :am and goes to work (agriculture ) ,lunch at 1 -2 pm ,again continues work and comes back at 6 pm ,dinner at 8 pm ,goes to bed at 10pm.

Past history:

No history of diabetis , hypertension,asthma,epilepsy,TB.

Personal history:

Diet : mixed 

Appetite: normal 

Bowel and bladder:regular 

Sleep:adequate

Family history:

No similar complaints in the family.

General Examination:

Patient is conscious coherent and cooperative.

Well oriented to time place and person.

Moderately build and moderately nourished.

Pallor -absent 

Icterus -absent

Cyanosis- absent

Clubbing- absent

Lymphadenopathy- absent

Edema- absent 

VITALS:

Temp- 98°F

RR- 16cycles per min

Bp- 100/60mmHg

PR- 83bpm

*SYSTEM EXAMINATION:

Abdominal examination- soft and non tender

Respiratory system-inspection- trachea central,normal respiratory movements,normal vesicular breath sounds.

Cardio vascular system- S1 ,S2 heard ,no murmurs

CNS Examination- no focal neurological deficits.

INVESTIGATIONS:

17/12/2022:

19/12/2022:

USG:

20/12/2022:

21/12/2022:

Provision diagnoses:

Viral pyrexia

Treatment:( 19/12/2022 - 22/12/2022)

Paracetamol -650 mg (Qid)

Pan 40mg -(Bd)

Optineuron -1 amp in 500 ml NS

Sucralfate syrup -10 ml (TID).

22/12/2022:

Fever reduced, neck pain and headache are subsided.