Case history
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Date of administration :2-12-2021
A 33 year old female who is homemaker came to the opd with chief complaint of fever since 5 days, loose stools & vomiting since 4 days , abscess since 1 week,arthralgia & anaemia since 2 months.
History of present illness :
Patient was apparently asymptomatic 2 months back, then the patients complaints of low grade feve with Polyarthralgia lasted for 15 days , patient used paracetamol & diclofinac but patient does not got relief . After 1 week patient took covid vaccine, the fever & Polyarthralgia still persisted then patient visited rheumatologist in month of October , the doctor advised Tab HCQ 200 mg OD (2 weeks), Tab prednisolone 20 mg OD 2 weeks
Then patient came to the kims with chief complaint of high grade fever with chills & rigor , vomiting which is non bilious and non projectile food or water as content , watery stool , large volume, mucous and no blood in stool and patient had a ruptured abscess on thigh
Past history:
Not a know case of diabetes, hypertension, asthama, epilepsy, TB
History of thyroid since one and half year
Personal history:
Dite : mixed
Appetite : lost since 2 months
Sleep : adequate
Bowel & bladder movements : abnormal
No addictions
Family history:
Patient mother had a history of diabetes & hypertension since 10 years
General physical examination:
Patient is conscious, coherent, co-operative
She is well oriented to time place and person
She is moderately build and nourished
Mild pallor
No icterus, cyanosis, clubbing, generalized lymphadenopathy
Mild dehydration
Vitals :
Temperature:Afebril
BP :80 /50 mmHg
PR:88bpm
Respiration rate: 12cpm
Systemic examination :
Cardiovascular system :
S1 and S2 heard
Respiratory system :
No wheezing
No Dyspnoea
Position of trachea : central
BAE +
Per abdomen :
Soft
CNS :
No abnormality directed
Investigations :
Povisional diagnosis : acute gastroenteritis ( infective)
Ruptured sebaceous cyst
Arthralgia
Normocytic normochromic anaemia with leucopenia
Treatment :
IVF NS & RL OPTINEURON 1 amp
INJ PANTOP 40 mg IV /OD
INJ METRAONIDAZOLE
INJ CEFTRIAXONE
TAB SPORLAC
TAB DOLO 650 mg
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