General medicine case-7

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Date of admission: 02/11/2021

A 40 year old female who is a farm worker by occupation presented to the OPD with chief complaints of fever, dry cough and breathlessness since 2 days.

History of present illness:

Patient was apparently asymptomatic 2 days back then developed high grade fever with chills which is intermittent, relieving on medication.

The patient also developed headache and vomitings(2-3 episodes/day).

Past history:

Not a known case of Hypertension, Diabetes mellitus, Asthma, Tuberculosis, Epilepsy.

Personal history:

The patient has a mixed diet.

Appetite is normal.

Bowel and bladder movements are normal.

Has no habits of smoking and alcohol consumption.

Treatment history:

The patient is not allergic to any known drugs.

General examination:

The patient is conscious, coherent and cooperative

 Pallor- Yes

Cyanosis- No

Lymphadenopathy- No 

Clubbing of fingers- No

Pedal edema- No

Vitals:

Temperature- 98⁰F

Pulse rate- 108 bpm

Blood pressure- 90/60 mmhg

Respiratory rate- 22 cycles per min

Investigations: 

Diagnosis: 

Viral pyrexia

Treatment:

1) IVF 20 NS

        20 RL

         10 DNS

@100 ml/hr

2) INJ PANTOP 40 mg IV OD

3) INJ OPTINEURON 1 amp in 100 ml NS IV OD

4) PLENTY OF ORAL FLUIDS

5) TAB DOLO 650 mg PO SOS

6) INJ NEOMOL 1 gm IV SOS ( if temp>101⁰F)

7)W/F BLEEDING MANIFESTATIONS; POSTURAL DROP IN BP.