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

           Pallor - present


           Generalised lymphadenopathy- 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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