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2/01/2023
Sushmitha didyala
Rollno 37
A 35 yr old female,resident of nakrikal,daily wage labour by occupation came with chief complaints of
1)fever since 1 week
2)headache since 1 week
HOPI: patient was apparently asymptomatic 1 week ago then she developed fever which is intermittent in nature and increasing at night time and decresing at morning associated with chills and headache. increase headache causing increase fever.
Fever id relieved with taking paracetamol.no history of nausea, vomiting,rashes,bodypain
--History of unilateral headache since 1 week which sever throbbing type of pain involving left fronto parietal occipital,pain is radiating to the neck,pain increases at night and due to the pain she wakes up at night,headache associated with phonophobia and blurring of vision(due to which she changed her spectacles),history of vomiting (1episode on 2nd jan morning )no history of tinnitus,there is decreased physical activity during episodes.there is tingiling sensation in hand and feet it is relieved with taking rest and medication. headache is aggrevated with stress, headache is relieved with using naproxen,no history of lacrimation,photophobia, depression,irritation,cravings.
--History of left loin pain since yesterday morning which is dragging type of pain.history of burning micturation since 5days and decreased urine output since 4days, decreased frequency,no aggrevating and relieving factors,no history of urgency, hematuria,nausea, vomiting
Daily routine:she wakes up around 5am and does her daily chores and gets her children ready,and have breakfast at 8:30or 9am and then sleeps for some time before she went to work (daily wage labour) but stopped since 7years and
And then she cooks lunch and watch tv from 2pm to evening(watching serials etc) then she have tea in the evening and later she prepares dinner and eat at 9pm and sleeps at 9:30pm
Past history: she has similar complainys 1yr back. she is a known case of hypothyroidism since 10years for which she is medicine (throxine,sodium I.P 75mcg).
She had renal caliculi 6years back and reduced by conservatively (some medication she does not remmeber)
She is not k/n/o diabetes mellitus,TB,epilepsy,CAD,asthma, hypertension.
Family history:no relevant family history
Personal history:
Diet-mixed
Appetite -reduced
Sleep-inadequate
Bowel and bladder-constipation
No addictions
No allergies present
General examination:
Patient is conscious,coherent and cooperative,
Moderatively built and nourished
On examination thyroid appears normal.
Pallor-present (anemia 8.8g/dl) under evaluation.
Icterus-absent
Cyanosis-absent
Clubbing -absent
Koilonychia-absent
Lymphadenopathy-absent
Edema - absent
Vitals -
RR:18cpm
PR:82bpm
Bp:100/70mmhg
Temp:99F(yesterday night)
Systemic examination:
Cvs:S1and S2 are heard and no abnormal sound heard.
Respiratory system:BAE+,normal vesicular breath sounds heard.
Per abdomen:
-examination of oral cavity is normal
**Inspection
-shape-normal(rounded)
-no flank fullness is seen.
-skin-no scars seen ,presence of linea 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.
Right handed person
HIGHER MENTAL FUNCTION
Counsious ,oreinted to time place person
Speech normal
Behaviour normal
Memory intact
Intelligence normal
Sensory system:
-fine touch: intact
-pain: normal
-temperature - normal
- vibration -normal
-stereognosis- normal
-two point discrimination-present
Meningial sign :
Kernigs sign negative
Brudzinski sign negetive
Provisional diagnosis:
Migraine /renal caliculi/UTI under evaluation
Investigations:
Complete urine examination
Hemogram
T3,T4,TSH levels
2nd jan 2023
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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