35 year old female with fever, cough and joint pains
Note: This is an online E Log book recorded by Anupreethi 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 2 weeks, dry cough since 2 weeks, joint pains since 2 weeks
HOP1: 35 yr old female patient housewife by occupation brought to casualilty with fever, cough and joint pains(knee joint, ankle joint, metacarpophalangeal joint . She had high grade, continuous fever associated with chills and rigors. She had similar fever with joint pains in June 2020 and June 2022 for which she went to local hospital and treated conservatively.
Negative History : No History of Headache,Hypertension,diabetes,Vomiting ,Chest Pain,Palpitations and Shortness of Breath, asthma
Past illness: patient was asymptomatic 12 years back and she developed abnormal uterine bleeding and swelling of uterus fibroids for which hysterectomy was done. History of epilepsy at the age of 6 years, used medication for 3 years and 1 episode at 10 years
Personal History: Mixed diet
Bowel And Bladder-Regular
Sleep Adequate
No Allergies And Addictions
Family History: Patient’s father has hypertension, epilepsy
General Examination:
Patient is Conscious,
Moderately Built and Nourished.
Pallor Absent
Icterus Absent
Clubbing Absent
Cyanosis Absent
Lymphadenopathy Absent
Edema Absent
Vitals :
Temperature - 98.4 degree c
Pulse 74/min
B.P 90/100mmHg
SpO2:95%
Lab diagnosis:
Treatment:
IV fluids @ 100ml/hr
Inj piptaz @ 4.5g IV/TID
Tab dolo @650mg PO/QID
Inj Optineuron@ 1 amp IV/OD
Inj pantop @ 40 mg IV/OD
Tab azithromycin @ 500mg PO/OD
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