35 YEAR OLD FEMALE WITH FEVER AND SEVERE HEADACHE
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.
02/01/2023
Blog by Janhavi Virani
Roll no 58
A 35 year old female resident of Nakrikal who is a daily wage labourer by occupation came with
CHIEF COMPLAINTS of :-
1. Fever since 1 week
2. Headache since 1 week
HOPI :-
Patient was apparently asymptomatic 1 week back then she developed fever which is intermittent in onset ( on and off ) increasing at night time and decreasing in the morning associated with chills and headache ( increased headache leading to increase in fever ).
Fever is relieved by taking anti pyretic . No history of nausea , vomiting , rash or body pain .
History of unilateral headache since 1 week which is severe throbbing pain in left fronto parietal occipital region radiating to the neck due to exposure of stress . Pain is causing her to wake up at night ( inadequate sleep ) .
Headache is associated with vomiting ( just 1 episode ) phonophobia and blurring of vision ( history of change in spectacles) , decreased regular physical activity , tingling sensation in hand and feet . It relieves on taking rest and medication .
No history of aura , photophobia , depression , irritability, cravings , diarrhoea/constipation.
She has history of burning micturition since 5 days associated with decreased urine output, decreased frequency, left loin pain which is dragging type pain ( since 1 day ) . No aggrevating and relieving factors . No history of urgency, hematuria , nausea , vomiting .
DAILY ROUTINE:-
She gets up at at around 5 in the morning does her daily chores and gets her kids ready for school then she has breakfast at 8:30 or 9 am and then sleeps for sometime before she goes to work which she has stopped going since 6 years .
PAST HISTORY:-
Similar episode one year back .
Not a known case of Diabetes, hypertension, epilepsy, cardiovascular disease and tuberculosis.
History of hypothyroidism 10 years back for which she is on daily thyroxine ( 75 mg ) supplements.
History of renal stones in the left kidney 6 years back for which she took conservative treatment.
FAMILY HISTORY :-
No significant family history .
PERSONAL HISTORY:-
Diet - mixed
Appetite - decreased
Sleep- inadequate
B&B - she is constipated
Addictions- none
NO H/o is any drug allergy
GENERAL EXAMINATION:-
Patient is conscious, coherent and cooperative
Well oriented to time. Place and person .
Moderately built and nourished
O/E - thyroid appears normal
Clubbed- absent
Cyanosis- absent
Icterus - absent
Edema - absent
FEVER CHART :-
VITALS:-
Temp - 99 F
PR - 84bpm
RR- 20 cpm
BP - 100/70 mm of Hg
SYSTEMIC EXAMINATION:-
CVS - S1 S2 heard , no murmurs present
RESP - bilateral Air entry present
normal vesicular breath sounds heard
ABDOMINAL-
examination of oral cavity is normal
**Inspection
-shape-normal(rounded)
-no flank fullness is seen.
-skin-no scars seen ,presence of striae.
-no dilated veins seen
-Movements of abdominal wall-no visible peristalsis,no visible pulsations
-umbilicus-inverted.
**Palpation
-tenderness-hypogastrium and left lumbar region
-warmth- present (fever)
-rigidity,guarding is absent
*no organomegaly, normal bowel sounds heard
CNS:no focal deficits are found.
Higher mental functions- normal
Brudzinski’s sign - absent
Kernig’s sign - absent
PROVISIONAL DIAGNOSIS:-
Migraine/ Left Renal Calculi / UTI
INVESTIGATIONS:-
Complete urine examination:-
Hemogram :-
Thyroid profiles :-
USG :-
TREATMENT:-
Inj-optineuron 1amp in 100ml of NS OD
IvF-@70ml/hr
Tab nitrofurantoin 100mg
Tab pan
Tab naproxen 250mg
Bp,temp,RR,PR check 4th hrly
Tab thyronorm 25mcg
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