gm e-mail log

Hi all, this is Mounika, a 5th sem  medical student
This is online E log book to discuss our patients health data shared after taking his guardians informed consent form

HISTORY:

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

HOPI:
 Pateint was asymptomatic one day back . from Tuesday afternoon she observed raise of temperature after she has done household chores which is associated with headache and neckpain.
Fever is not associated with chills. 
she took a tablet without eating and had an episode of vomting.and at night she took another tablet without eating had another episode of vomiting ,even after taking medications , there is high raise of body temperature .so she was taken to a RMP doctor and was given Dolo 650 and an injection.
-No complaints of burning micturition, pain abdomen, loose stools, cough, cold, SOB

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

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

Treatment history:
Not significant

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

Family history :
Not significant


GENERAL EXAMINATION:
 weakness at the time of admission.
Pallor: absent 
Icterus: absent 
Cyanosis: absent 
Clubbing: absent 
Lymphadenopthy: absent 
Edema : absent

VITALS: 
TEMP 98.6F
BP   120/80
PR    110
RR  :18
SpO2.  98%

Systemic Examination
CVS
S1 S2 heared
No murmurs

RESPIRATORY system 
Dyspnoea : no
Wheeze : no
Postion of trachea: central

ABDOMEN 
Shape of abdomen: obese
There is no free fluids
Liver and spleen is not palpable
Bowel sounds are normal

CNS
Conscious with normal'speech
There is no sign of meningeal irritation
Glasgow scale 15/15

Investigations

Fever chart
 
Ultrasound

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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