Case of a 33 year old female with fever from the past 3 days

 Note : This is an ongoing case and will be updated as and when we find new information . 

CHIEF COMPLAINTS : 

A 33 year old female presented to the hospital 3 days ago with complaints 

• Fever and chills from the past 5 days 
• Vomiting  after eating food from the past one day . 

HISTORY OF PRESENTING ILLNESS : 

The Patient was apparently asymptomatic 5 DAYS  back . 

5 days ago , the patient complained of fever accompanied with chills . 

She took 3-4 paracetamol tablets for 2 days  , and the fever regressed but reappeared. 

Characteristics of the fever : High grade fever , intermittent . 

3 days ago the patient complained of vomiting  after eating food. 

The patient presented to the hospital 3 days ago . 

HISTORY OF PAST ILLNESS/ Surgeries 

The patient underwent tubectomy 17 years ago. 

No history of DM, TB, HTN, CAD, ASTHMA. 

DRUG HISTORY 

For the fever , before visiting the hospital , the patient took 3-4 paracetamol tablets in a duration of 2 days . 

PERSONAL HISTORY 

• Married 
• Occupation : Sweeper 
• Appetite : Normal 
• Diet : Mixed 
• Bowel movement : regular
• Micturition : normal 
• No history of alcohol consumption or smoking 

FAMILY HISTORY 

• no relevant family history 

MENSTRUAL HISTORY 

• the patient has regular cycles 
• Number of days bleeding : 5 days 
• Duration of cycle ; 28 days 
• The patient underwent tubectomy 17 years ago 
• G3L3P3

GENERAL EXAMINATION : 

• The patient is concious , coherent 
• NO pallor , icterus , cyanosis , clubbing , lymphadenopathy , koilonychyia
• Moderately built , moderately nourished 
• 
  
  
  
  

VITALS 

• Temperature : 99 degree F
• Pulse : 68 beats per minute , no radio radial delay, normal character , and rhythm . 

CVS EXAMINATION : 

• S1 , S2 present 
• No murmurs or thrills 

RESPIRATORY SYSTEM Examination : 

• Breath sounds normal 

PER ABDOMEN : 

• No tenderness 
• no palpable spleen or liver 
• No free fluid 

CNS EXAMINATION 

• The patient is concious coherent and oriented to time place person . 
• Higher mental functions are normal 
• Cranial nerves : intact 

INVESTIGATIONS

 

DIAGNOSIS : Viral pyrexia 

TREATMENT 

1. TAB DOLO 650 mg 6th hourly 

2. INJ PANTOP 40 mg IV OD

3. INJ NEOMOL 1 gm IV

4. INJ ZOFER  4 mg IV DB