20 YR OLD FEMALE WITH FEVER AND HEADACHE

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"

DR. JATIN SHARMA 

Roll no. 56

A 20 YEAR OLD FEMALE WITH FEVER AND HEADACHE 

Date of admission : 31-1-23

Presenting complaints :

Fever since 1 week

Bloating since 1 week 

Headache and neck pain since 1 week 

Vomiting for 2 days one week ago

History of presenting illness:

Patient Was apparently asymptomatic one week back then she developed bloating and indigestion. She c/o fever since 1 week of high grade not associated with chills and subsidies on taking medication. 

C/o vomiting for 2 days 1week ago contained food particals, non projectile, non bile stained 

No h/o cough, cold, burning micturition 

Her daily routine : 

She wakes up around 5am then she goes to train herself to become a police officer for 2hrs, after which she gets ready and has her breakfast which usually comprises of one bowl rice with curry or idly or dosa etc. Then she leaves to study (bsc). She has her lunch at college around 1-2pm which comprises of homecooked rice and curry or chapati with curry. She returns home around 5pm and helps out her family in the house. After which she has her dinner around 8pm which usually comprises of rice and curry or chapati with curry. She then goes to sleep around 10pm.

Past history : 

Not a k/c/o HTN / DM / Asthma / CAV / CAD

Personal history :

Sleep: adequate 

Appetite: decreased

Diet: mixed

Bowel and bladder movements: normal 

Addictions: none 

Menstrual history : 

Age of menarche - 13yrs 

28/5 days cycle 

LMP  23-1-23

Dysmenorrhea present 

Family history : 

No similar complaints in family 

General examination :

Patient Is conscious, coherent, cooperative moderately built and well nourished 

pallor - Absent 

icterus - Absent

clubbing - Absent

cyanosis - Absent

lymphadenopathy  - Absent

Edema  - Absent

Vitals:

Temp. - 97.6F

Bp - 110/70 mmhg 

PR - 102 BPM

RR - 18 CPM

Systemic examination :

CVS - S1S2 present, no murmur

RS - Bilateral air entry present, trachea central in position 

CNS - Higher mental functions intact 

P/A - Soft, Tenderness present in epigastrium

Clinical images with investigations:

     chest xray PA view done on 1-2-23

     ECG done 31-1-23

 

    USG abdomen done on 1-2-23

    blood investigations done on 31-1-23

    Fever chart 

Diagnosis :

Pyrexia under evaluation ?UTI with primary dysmenorrhea

Treatment :

* IV fluids 1 unit NS @100ml/hr

* inj neomol 1gm iv sos

* Inj pan 40 mg iv od

* Inj zofer 4mg iv sos

* tab pcm 650mg po 6th hrly 

* vitals monitoring 

SOAP NOTES :

Ward patient admission date 31-1-23 

Date - 2/2/23

Unit-2

Dr Aashitha  (Sr)
Dr pradeep (Pg 3)
Dr vinay (pg 3)
Dr narsimha (pg 2)
Dr ajay  (pg 1)
Dr prachethan ( pg 1)
Dr Santosh Kumar (intern)
Dr Jatin Sharma ( Intern)
Dr preethi (intern)

S
Burning micturition
Headache
Pain in umbilical region
No fever spike
No vomiting

O
BP- 110/80 mmhg
Pulse- 82bpm
RR-16cpm
Afebrile
CVS- s1s2 +, no murmurs
RS- b/l air entry +, no added sounds
P/A- soft, tenderness +
CNS- HMF intact

A
pyrexia under evaluation ?UTI

P
* IV fluids 10NS @50ml/hr
* Inj pan 40 mg iv od
* Inj zofer 4mg iv tid
* tab pcm 650mg po tid
* vitals monitoring