47 year old female with fever and pain abdomen
A 47 year old female,resident of Nalgonda came to our medicine OPD with chief complaints of
Fever since 3 days which is of high grade and associated with chills
Pain abdomen since yesterday morning in the epigastrium
Vomitings since yesterday 5 episodes,non bilious ,non projectile
-No H/O cold,cough,headache, SOB, palpitations
-No H/O rash, ,loose stools,melena, constipation
- No H/O burning micturition, hematuria
PAST HISTORY-K/C/O Hypertension since 5 years on regular medication Tab.Olmesartan 40mg
Not a K/C/O DM,TB,Epilepsy,Asthma,CVD,CAD.
PERSONAL HISTORY-
Mixed diet
Normal appetite
Adequate sleep
Regular bladder and bowel movements
No addictions
FAMILY HISTORY-
No similar complains in the family.
No history of Diabetes, Hypertension,TB, Asthma, CAD,CVD.
GENERAL EXAMINATION-
Patient was conscious, coherent, co- operative. Well oriented to time, place and person.
Moderately built and moderately nourished .
No pallor
No icterus
No clubbing
No cyanosis
No lymphadenopathy
No edema
VITALS-
TEMPERATURE- Afebrile
BP-130/90mm of hg
PR-90 BPM
RR-19 CPM
SPO2- 98% at Room air
GRBS- 93 mg/dl
SYSTEMIC EXAMINATION-
CVS EXAMINATION-
S1, S2 heard
No murmurs
RESPIRATORY SYSTEM EXAMINATION-
Trachea-midline
Bilateral air entry present
Normal vesicular breath sounds heard
No additional sounds
PER ABDOMINAL EXAMINATION-
INSPECTION-
Shape- Scaphoid
Umbilicus- central and inverted
Movements with respiration- equal in all quadrants, rises with inspiration and falls during expiration
No visible pulsations
No visible scars or sinuses seen
No engorged veins
PALPATION-
No local rise of temperature
No tenderness in any quadrants of abdomen
Liver and spleen- impalpable( no organomegaly)
PERCUSSION-
Tympanic note
AUSCULTATION-
Bowel sounds present
CNS EXAMINATION-
No focal neurological deficits
INVESTIGATIONS-
PROVISIONAL DIAGNOSIS- VIRAL PYREXIA WITH THROMBOCYTOPENIA
WITH DENGUE NS1-POSITIVE
TREATMENT-
1. IV Fluids NS,RL@ 100 ml/hr
2.Plenty of oral fluids
3.Inj.Pan 40 mg/IV/OD
4.Tab.Olmesartan 40 mg/PO/OD
5. Inj.Tramadol 1 amp in 100 ml NS/IV/SOS
6.Inj.Zofer 4 mg/IV/BD
7.BP/PR/SPO2 monitoring
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