Patient with H/O of pain abdome fever

  

A 29 yr old female patient name  resident of narketpally came to the opd with  cheif complaints  of 

Pain abdomen  since 20 days associated with nausea

H/0 of fever 1 month back - for 10-15 days which subsided after medication 

HOPI

Patient is apparently asymptomatic 13 yrs back then she gave birth to a baby with c section after few months pt developed fearfullness, palpitations, which she underwent many hospital  visits ,took medication. 

6yrs back patient developed generalized body itching to  which she went to dermatologist  ,took medication 

5ys back she had h/o of excessive menstrual bleeding  for which she was told she had infection (cervicitis) , took medication. 

1-2 yrs back h/o of fever ,decreased  platelets (dengue) treated conservatively

1 month -  low grade fever loss of Apetite, palpitations,  chest discomfort. 


PAST H/O

Not a k/c/o diabetes ,HTN, TB,asthama,cvd , epilepsy.

PERSONAL H/o

diet - mixed

Apetite - normal

Bowel , - regular

Burning  micturition present 

Sleep - adequate 

Addictions -no  h/o of smoking .

FAMILY  H/O

No significant  family h/o

GENERAL  EXAMINATION 

patient is conscious, Cooperative, coherent, oriented to time,  place, person

Vitals 

 Afebrile ,Bp   , HR  ,PR , GRBS , spo2 

Pallor present

No cyanosis

No clubbing

No icterus ,

No edema

No Lymphadenopathy 




SYSTEMIC EXAMINATION 

Cvs

S1 s2 heard no murmurs

Respiratory system

Normal vesicular breath sounds,  no wheeze , no dyspnea , trachea is central

Abdomen

Shape of abd - obese

No tenderness 

No palpable mass, fluid , bruit

No palpable liver  , spleen

P/V , P/R  NORMAL

CNS

Patient is conscious , speech normal, no meningeal signs

Cranial nerve ,Sensory, motor examination ,reflexes , gait normal , no cerebral signs

PROVISIONAL DIAGNOSIS 

Urinary tract infection 

INVESTIGATIONS 

CBP,CUE ,RFT , ECG ,XRAY ,USG -ABD









TREATMENT 

IVF NS 100ML/hr

inj optineuron 1amp in 100ml NS IV /OD

inj PAN 40mg IV/OD

inj ZOFER 4mg IV /OD

BP /PR/TEMP/SPO2 monitoring 


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