26 YEAR OLD FEMALE WITH FEVER AND SOB

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PRESENTING COMPLAINTS

26 YEAR OLD FEMALE PRESENTED WITH THE CHIEF COMPLAINTS OF FEVER ASSOCIATED WITH CHILLS AND RIGORS SINCE 5 DAYS. 

C/O SOB SINCE 5 DAYS

HISTORY OF PRESENT ILLNESS:

PATIENT WAS APPARENTLY ALRIGHT 5 DAYS BACK. SHE HAD FEVER WHICH IS LOW GRADE, INTERMITTENT, ASSOCIATED WITH CHILLS AND RIGORS WITH EVENING RISE OF TEMPERATURE AND RELIEVED BY TAKING MEDICATION. 

C/ O SOB SINCE 5 DAYS (GRADE II)

NO ORTHOPNEA, NO PND, NO PEDAL EDEMA.

H/O VOMITINGS. 2 EPISODES YESTERDAY, NON PROJECTILE, NON BILIOUS, FOOD AS CONTENTS, NON FOUL SMELLING.

NO H/O LOOSE STOOLS, CHEST PAINS, PALPITATIONS, SWEATING, NO PAIN ABDOMEN

HISTORY OF PAST ILLNESS: 

H/O OF DELIVERY BY LSCS ON 1/02/2023

H/O ? ASTHMA SINCE 2 YEARS (USING UNKNOWN INHALER)

N/K/C/O HTN, TB, DM, EPILEPSY, CVA, CAD

OBTETRIC HISTORY: 

AGE AT MARRIAGE: 23

PARA 2

STILL BIRTH: 1 

NO OF LIVING CHILDREN : 1

BIRTH HISTORY: LSCS

GENERAL EXAMINATION: 

NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, OEDEMA

VITALS: 

TEMPERATURE: 97.5

BP: 110/70

PR: 134/MIN

RR: 22/MIN

GRBS: 109 MG/DL

SYSTEMIC EXAMINATION

CVS: S1 S2 HEARD, NO MURMURS

RS: DYSPNEOA +, NVBS

ABDOMEN: SOFT, TENDER 

CNS: PATIENT IS CONSCIOUS

NO SIGNS OF MENINGEAL IRRITATION

NFND

INVESTIGATIONS :

ON 07/03/2023 

ON 08/03/2023

POST SDP TRANSFUSION

ULTRASOUND REPORT

IMPRESSION: 

MILD HEPATOMEGALY

BORDERLINE SPLENOMEGALY

GALL BLADDER WALL EDEMA WITH INCREASED WALL THICKNESS

2D ECHO:

IMPRESSION: 

NO MR/ AR/ TR

NO RWMA. No AS/MS

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION, NO PAH/PE

SDP TRANSFUSION:

1 SDP TRANSFUSION DONE ON 07/03/2023 AT 3.15 PM

DIAGNOSIS:

VIRAL PYREXIA WITH THROMBOCYTOPENIA 

VOMITING + (1 EPISODE)

TREATMENT 

1. IV FLUIDS

2. INJ ZOFER 4MG /IV/BD

3. INJ PAN 40 MG /IV / OD

4. TAB. PCM 650 MG/ PO/ SOS

5. INJ NEOMOL 2 GM IV / SOS

6. VITALS MONITORING 4TH HOURLY

7. WATCH FOR HYPOTENSIVE SYMPTOMS