Case of a 33 year old female with fever

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This is the case of a 33 year old lady , who is a sweeper by profession .

CHIEF COMPLAINT

The patient presented to the casualty with high grade fever since 3 days , with chills. 

HISTORY OF PRESENTING ILLNESS

The fever was intermittent and temperature would reduce after taking medicines.

After getting admitted to the hospital she had 2 episodes of vomiting .

PAST HISTORY

She has no history of any previous ailments . 

She underwent a tubectomy 17 years ago.

PERSONAL HISTORY 

No history of DM, HTN, TB , Asthma and epilepsy 

Appetite is normal

Diet - Non veg mixed diet. 

Bowel movement- normal

Bladder movement- normal

No addictions.

MENSTRUAL HISTORY 

Normal menstrual cycle and flow .

OBSTETRICS HISTORY

G3L3P3

All deliveries were normal.

Underwent tubectomy 17 years ago.

FAMILY HISTORY

No relevant family history.

VITALS

 PR =68 bpm 

 RR= 18 /min

 TEMP= 99 F

 SPO2= 99% at room air. 

GENERAL EXAMINATION

Patient is conscious , coherent and cooperative.

Moderate built .

There is no pallor, cyanosis ,icterus,  lymphadenopathy and clubbing .

SYSTEMIC EXAMINATION 

CVS:- 

 S1, S2 heard 

 

RESPIRATORY SYSTEM :- 

 BAE+ 

 NVBS heard 

 PER ABDOMEN :-

No tenderness

No free fluid

No palpable spleen or liver 

CNS

Patient is conscious and coherent.

Speech is normal.

PROVISIONAL DIAGNOSIS-

?Viral pyrexia

INVESTIGATION ORDERED-

CBP, Rapid dengue test , Serum electrolytes, Serum creatinine, smear for malarial parasite , chest X ray , ECG  

TREATMENT-

1. 1.IVF 20 NS, 20 RL , 10 DNS - @100 ml/hr

    2.T. Dolo 650mg PO QID - 6 th hourly

    3. Inj Pantop 40 mg IV OD

    4.Inj Neomol 1gm IV (if temperature - more than 101 F)

    5. Plenty of oral fluids.

    6. Temperature chart plotting 4 th hourly.

    7.GRBS 12th hourly 

    8. BP/PR charting - 4th hourly

    9. Inj Zofer 4mg IV BD