A 35 yr old female with viral pyrexia

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A 35 yr old female came to the OPD on 15-12-2022, 11:25 am with c/o fever and pain abdomen and generalized weakness since 10 days.

HISTORY OF PRESENT ILLNESS:

This patient is a 35 yr old female R/O Oligonda , daily wage laborer by occupation. She is apparently asymptomatic 10 days back and developed fever which is intermittent low grade a/o chills and rigors , dizziness and headache. She also has h/o generalized weakness, body pains, joint pains . She took Dolo 650mg 3-4 times a day for 10 days. She is having burning micturition from 10 days.  She had 3 episodes of vomiting and h/o loose stools 5 days back and relieved on medication .

All throughout her illness the patient was able to carry on with her daily activities and was going to work everyday. Her daily routine is waking up at 6 am in the morning, drinking tea at 7:30 am , having her breakfast as rice at 9 am and leaving to work. She is going to have her lunch as rice with curry at 2 pm and continue with her work. She used to return home by 5:30 pm and have tea at 6:00 pm and her dinner as rice with curry at 9 pm. She goes asleep by 10 pm.  

HISTORY OF PAST ILLNESS: 

She had TB 8yrs back & took ATT for 6 months then she was relieved
Not k/c/o  HTN/ DM/ CVA/ CAD/  epilepsy/ asthma/ thyroid
No  drug allergies 

SURGICAL HISTORY: 

LSCS 15yrs back

Tubectomy 14 yrs back  no blood transfusions

PERSONAL HISTORY:

1. Married 
2. Takes mixed diet.
3. appetite lost since 15 days
4. Irregular bowel and bladder movements( passes stools once in 2-3 days in the past 7 days  & burning micturition since 7 days)
5. No known allergies.
6. teetotaler

FAMILY HISTORY: 

n/k/c/o DM, HTN, Heart disease, asthma, stroke, cancers, any hereditary disease.

MENSTRUAL HISTORY:

Age of menarche: 13yrs

menstrual cycle:  25/3

LMP: 24-10-2022

OBSTETRIC HISTORY: G2P2L2

 Age at marriage:  21

Gravida: 2 

para: 2 

no. of living children: 2

Family planning: permanent sterilization (tubectomy 14 yrs back)

BIRTH HISTORY: 

1st pregnancy: LSCS

2nd pregnancy: NVD

GENERAL EXAMINATION:

Ht:157 cm   Wt: 41 kg

Vitals: 

• BP: 120/80mmHg
• RR: 16cpm
• PR: 68bpm
• Temp: 98.9 °F

• Pallor +
• icterus -
• clubbing - 
• cyanosis -
• lymphadenopathy -
• edema -
• no malnutrition
• no dehydration

SYSTEMIC EXAMINATION:

CVS: S1, S2 heard

          no thrills

          no murmurs

RESPIRATORY SYSTEM:

           no Dyspnoea 

           no wheeze

           BAE +

          Trachea central position

          vesicular Breath sounds heard

ABDOMEN:

          Shape of abdomen: scaphoid

          no tenderness 

          no palpable mass

          No free fluid 

          no bruits 

          no organomegaly

          normal hernial orifices

          bowel sounds+

CNS: C/C/C to time, place, person

          No signs of meningeal irritation 

          no focal neural deficit found

          normal speech

          functions of cranial nerves, motor & sensory system are normal

Reflexes:  

       biceps triceps supinator knee ankle

right ++       ++          ++             ++         ++

left   ++        ++          ++             ++         ++

CEREBELLAR SIGNS:

Finger nose in coordination: yes

Knee- heel in coordination: yes

GAIT: normal

MUSCULOSKELETAL SYSTEM:     N

SKIN : N

EXAMINATION OF BREAST, ENT, TEETH & ORAL CAVITY, HEAD & NECK:

NORMAL

PROVISIONAL DIAGNOSIS:

?? VIRAL PYREXIA UNDER EVALUATION

INVESTIGATIONS:

 pallor + ve

 no pedal edema

no malnutrion

ECG

CBP

LFT & RFT

USG

TREATMENT:

1. T. PCM 650 MG PO/ TID
2. T. Cetrizine  PO/OD
3. Syp. Ascoril D 15ml PO/ TID
4. T. Zofer 4mg PO/BD
5. T. MVT PO/OD
6. T. OROFER XT PO/ OD
7. T. PAN 40MG PO/OD