52/F with pyrexia and body pains

NAME: Meghana.M

Roll no: 95

Batch: 2017

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"

52 year old, female farmer by occupation, came with complains of fever and cough since 14 days 

Patient was apparently asymptomatic 15 days back. Then she tripped and had a fall in bus stop. 

Injury to jaw and bled and had a suture. 

loss of consciousness for 15 minutes. 

Post ictal confusion is absent 

Fever since 14 days low-grade associated with chills and Rigors intermittent insidious in onset, no diurnal variation, decreased on taking medications

Cold and cough, present cough associated with sputum. 

Headache diffuse, intermittent, insidious and onset associated with nausea photophobia present.

Phonophobia present. No association with lacrimation.

General examination:

Patient is conscious coherent, cooperative, 

no pallor icterus, cyanosis, clubbing, lymphadenopathy or edema of feet

Bp: 120/90mmhg

Pr: 82bpm

Rr:20cpm

Temp: 98F

Cvs: S1S2 heard

Rs: BAE + NVBS

P/A:

Soft and non tender, bowel sounds present

Cns:

Motor power:.    UL.         LL

   R                     5/5         5/5

   L                      5/5         5/5

Tone normal in all 4 limbs.

Reflexes:.     

           B     T     S     A    K     P

    R.   2+   2+   2+   -   2+   Mute 

    L.   2+   2+   2+   -   2+    Mute

Investigations: 

Hemogram: 

Hb-11.5 mg/dl

Pcv- 36.7

Tlc- 7800 cells/cu mm

Plt- 3.22 lakh/cu. mm

ESR: 60mm 1st hour

Rft:

Blood Urea: 21

S.creatinine: 0.9

Na: 140

K: 3.9

Cl: 103 

Ecg

Chest xray

Fever chart

PROVISIONAL DIAGNOSIS: PYREXIA UNDER EVALUATION 

TREATMENT:

Date: 8/3/23

1.Plenty of oral fluids

2.Inj. OPTINEURON 1 amp in 100ml NS IV OD 

3.Inj. NEOMOL 1gm if temp >102F. Iv Sos

4.Tab. Dolo 650mg po tid

5.Syp. Ascoril Ls 15ml po tid

Date: 9/3/23

1.Plenty of oral fluids

2.Inj. OPTINEURON 1 amp in 100ml NS IV OD 

3.Inj. NEOMOL 1gm if temp >102F. Iv Sos

4.Tab. Dolo 650mg po tid

5.Syp. Ascoril Ls 15ml po tid

Date: 10/3/23

1.Plenty of oral fluids

2.Inj. OPTINEURON 1 amp in 100ml NS IV OD 

3.Inj. NEOMOL 1gm if temp >102F. Iv Sos

4.Tab. DOLO 650mg po tid

5.Tab. LEVOCETRIZINE 5mg Po od Hs

6.Syp. ASCORIL Ls 15ml po tid