A 36 YEAR OLD FEMALE WITH FEVER, VOMITINGS AND ABDOMINAL PAIN

 

36 year old female with fever, vomitings and abdominal pain

 E-LOG GENERAL MEDICINE

Hi, I'm  Likitha , a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

Case scenario -

36 year old female, housewife by proffesion came to OPD with chief complaints of

  •  fever since a week 
  • Pain in the abdomen since 5 days 
  • Vomitings since 3 days 

History of presenting illness-

Patient was apparently asymptomatic 1 week back, then she developed fever which was associated with chills and rigor 

This was followed by pain in abdomen which developed 5 days back in the epigastric region  which was sudden in onset and it was  dragging type 

Vomitings since 3 days which was non bilious and non projectile - 5 to 6 episodes a day 



History of past illness-

No history of DM, Hypertension, Tuberculosis, Asthma, Epilepsy

Hysterectomy was done 17 years ago 


Personal History-

Married

Mixed diet

Bowel movements normal

Micturition normal

No known allergies 


FAMILY HISTORY 

- not significant

 

GENERAL EXAMINATION 

- No - pallor /icterus / cyanosis / lymphadenopathy / clubbing 

- BP - 90/80 mmg

- PR - 106 /min

-RR- 18 /min

- SPo2 -98% at RT

- Temp - 101 degree F



SYSTEMIC EXAMINATION


— CVS 

- Thrills : No 

- Cardiac sounds - S1 , S2 heard 

- Cardiac murmurs : No 


— RS 

- Dyspnea : No 

- Wheeze : No 

- Position of Trachea : central 

- Breath sounds : vesicular


— ABDOMEN 

- Shape of abdomen : obese

- tenderness present , no palpable mass 

- Hernial orrifices : Normal 

- No fluids 

- Liver and Spleen are not palpable

- Bowel sounds : yes


— CNS 


- patient is conscious 

- speech is normal 

- No signs of meningeal irritation 

- Higher motor functions intact 


Investigations -







Provisional diagnosis -



Treatment-

8/8/22

•IVF - 20 NS 10RL @75ml/hr

• Inj. Zoffer 4mg/IV/TID

• Tab. Naproxen 250 /TID

• Inj. Pcm 1g/IV/SOS if temp >=101F

•Tab. Pcm 650mg po/ TID

•Tab. Vertin 16mg po/ BD


9/8/22

•IVF - 10 NS 10RL @75ml/hr

• Inj. Zoffer 4mg/IV/TID

• Inj. pan 40mg po/OD 

• Inj. Pcm 1g/IV/SOS if temp >=102F

•Tab. Pcm 650mg po/TD

•Tab. Vertin 16mg po/BD

• Inj. Monocef 1gm/IV/BD

• Syp. Cremaffin 10ml 


10/8/22

•IVF - 10 NS 10RL @75ml/hr

• Inj. Zoffer 4mg/IV/TID

• Inj. pan 40mg po/OD 

• Inj. Pcm 1g/IV/SOS if temp >102F

•Tab. Vertin 16mg po/BD

• Inj. Monocef 1gm/IV/BD

• Syp. Cremaffin 10ml 


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