36yr old female with raise of body temp

 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. 

HISTORY :

A 36yr old female came to OPD with complaints of raise in body temperature, headche and neckpain.

HOPI:
 Pateint was asymptomatic before one day and pt told that she did household chores after that she observed raise of temp along with headache and neckpain from Tuesday afternoon .she took a tablet without eatg and had an episode of vomting.and at night she took another tablet without eatg had another episode of vomiting ,at 11 pm  patient felt that high raise of body temperature .At night aftr raise of temp she was taken to a RMP doctor and given Dolo 650 and an injection..next day mng patient came to OPD.
No c/o burning micturition.

Daily routine:
she wakesup at 6am and will do her house chores before one month she did a handloom work for that one month.

VITALS:
Temp 98.6F
SPO2 98%
BP 120/80
PR 110
RR 18

GENERAL EXAMINATION:
 weakness at the time of admission.
Pallor: absent 
Icterus: absent 
Cyanosis: absent 
Clubbing: absent 
Lymphadenopthy: absent 
Edema : absent
Temp: 98.6F
Pulse rate  110/min

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM:
SpO2. 98%
RR:18
BAE+

CVS;
S1 and S2 heard

Abdomen:
Shape: normal
No tenderness there is no freefluids
Liver and spleen not palpable 

Past illness:
Not a known case of asthma, HTN,DM,TB and any CVS diseases, epilepsy.

Personal history:
Diet: mixed
Sleep: adequate
Bowel and bladder movements: normal
Habits: none

Family history :
Not significant

Treatment history:
Not significant 

FEVER CHART

ULTRA SOUND 
OTHER INVESTIGATIONS:
ECG

Provisional diagnosis:
Viral pyrexia

Treatment:
27/07/2022:

 1) InjPAN .40mg..IV OD
2) Inj ZOFER 4mgIV BD
3) IVF 20NS 100ml/hr slow IV
4) IVF 10RL 100ml/hr slow IV
5) Temp charting for 4th hrly
6) Inj MONOCEF 1gm IV BD
7) TAB DOLO 650mg PO  Q/D
8) Inj NEOMOL 1 gm IV
9) TAB ULTRACET 1/2TAB Q/D

28/07/2022:

1) InjPAN .40mg..IV OD
2) Inj ZOFER 4mgIV BD
3) IVF 10NS 50ml/hr slow IV
4) IVF 10RL 50ml/hr slow IV
5) Inj MONOCEF 1gm IV BD
6) TAB DOLO 650mg PO Q/D
7) Inj NEOMOL 1 gm IV
8) TAB ULTRACET 1/2TAB Q/D








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