Viral pyrexia

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HISTORY :

A 36yr old female came to OPD with complaints of raise in body temperature, headche and neckpain.

HOPI:

 Pateint was asymptomatic before one day and pt told that she did household chores after that she observed raise of temp along with headache and neckpain from Tuesday afternoon .she took a tablet without eatg and had an episode of vomting.and at night she took another tablet without eatg had another episode of vomiting ,at 11 pm  patient felt that high raise of body temperature .At night aftr raise of temp she was taken to a RMP doctor and given Dolo 650 and an injection..next day mng patient came to OPD.

No c/o burning micturition.

Daily routine:

she wakesup at 6am and will do her house chores before one month she did a handloom work for that one month.

VITALS:

Temp 98.6F

SPO2 98%

BP 120/80

PR 110

RR 18

Past illness:

Not a known case of asthma, HTN,DM,TB and any CVS diseases, epilepsy.

Personal history:

Diet: mixed

Sleep: adequate

Bowel and bladder movements: normal

Habits: none

Family history :

Not significant

Treatment history:

Not significant 

GENERAL EXAMINATION:

 weakness at the time of admission.

Pallor: absent 

Icterus: absent

Cyanosis: absent 

Clubbing: absent 

Lymphadenopthy: absent 

Edema : absent

Temp: 98.6F

Pulse rate  110/min

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM:

SpO2. 98%

RR:18

BAE+

CVS;

S1 and S2 heard

Abdomen:

Shape: normal

No tenderness there is no freefluids

Liver and spleen not palpable 

Provisional diagnosis:

Viral pyrexia

Investigations:

FEVER CHART

Other investigations 

ECG

Treatment:

27/07/2022:

 1) InjPAN .40mg..IV OD

2) Inj ZOFER 4mgIV BD

3) IVF 20NS 100ml/hr slow IV

4) IVF 10RL 100ml/hr slow IV

5) Temp charting for 4th hrly

6) Inj MONOCEF 1gm IV BD

7) TAB DOLO 650mg PO  Q/D

8) Inj NEOMOL 1 gm IV

9) TAB ULTRACET 1/2TAB Q/D

28/07/2022:

1) InjPAN .40mg..IV OD

2) Inj ZOFER 4mgIV BD

3) IVF 10NS 50ml/hr slow IV

4) IVF 10RL 50ml/hr slow IV

5) Inj MONOCEF 1gm IV BD

6) TAB DOLO 650mg PO Q/D

7) Inj NEOMOL 1 gm IV

8) TAB ULTRACET 1/2TAB Q/D