30 year old female came with Fever and vomitings
Note: This is an online E Log book recorded by Anupreethi(20) Anirudh(11) to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.
Chief complaints: Fever since 3 days, vomitings 5 episodes(13th June 2022), unable to walk since 1 day.
HOP1: 30 yr old female patient sweeper by occupation brought to casualilty with fever and vomitings. She had low grade, intermittent fever which relieves on medication not associated with chills and rigors.
She had 5 episodes of vomitings which contained food particles, non projectile and non foul smelling. She needed support for walking.
Negative history: no history of shortness of breath, cough, loose stools, asthma,tuberculosis, diabetes
Past illness- hypertension since 2 years(Telmisartan-drug)
Personal History: Mixed diet
Bowel And Bladder-Regular
Sleep Adequate
No Allergies And Addictions.
Family History: not significant
General Examination:
Patient is Conscious,
Moderately Built and Nourished.
Pallor Absent
Icterus Absent
Clubbing Absent
Cyanosis Absent
Lymphadenopathy Absent
Edema Absent
Vitals :
Temperature - afebrile
Pulse 114/min
B.P 140/80mmHg
SpO2:98%
GRBS: high
Systemic examination:
ABDOMEN: Palpable liver, no tenderness, distended abdomen.
Lab diagnosis:
Treatment history:13/6/22
IVF NS@100ml
Inj Human Actrapid (1ml+39ml NS)@6ml/hr
Inj Monocef@1 gm x IV x BD
14/6/22
IVF20NS@100ml/hr
Injection human actrapid insulin
1ml +39ml NS @ 6ml/hr
GRBS 1hourly
Injection monocef 2gm×IV×BD
Monitor vitals hourly
Injection zoter 4mg IV BD
Injection pan 40mg IV BD
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