General medicine case 8

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3rd December 2021

A 33yr old female came to OPD with chief complaint of fever since 5days, vomiting and loose stools since 4days and joint pains since 15days.

She has an abcess over left thigh since 5days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2months back.Then she had H/O low grade fever associated with joint pains lasted for 15days for which she used tab.paracetamol and diclofenac and the patient didn't get relief.

She took covid vaccine.

 Fever,small and large joints associated with swelling around joints still persisted.Then patient visited rheumatologist in the month of October.The doctor advised Tab.Hydroxychloroquine 200mg OD for 2weeks 

Tab Prednisolone 200mg OD for 2weeks

Tab Azathioprine 50mg OD for 2weeks

She came to our hospital with

 Fever-high grade associated with chills and rigor

Vomiting:non bilious,non-projectile,food and water as content

Stools:watery,large volume, mucous,no blood in stools.

Swelling on left anterior thigh since 5 days which is sudden in onest, gradually increased in size associated with pain,ruptured spontaneously with pus discharge.

HISTORY OF PAST ILLNESS:

H/O thyroid since 1 and half month 

No history of DM

No history of hypertension

No Malena and hematuria

PERSONAL HISTORY:

Appetite is lost since 2months

Mixed diet 

Sleep is adequate

Regular bowel movements

Bladder movements:Abnormal micturation- urgency +

No addictions

FAMILY HISTORY:

H/O DM and hypertension since 10yrs(mother)

MENSTRUAL HISTORY:

LMP :11/9/2021

She has irregular menstrual cycle since 2months 

OBSTETRIC HISTORY:

Age at marriage:18yrs

Age at first child birth:19yrs

Gravida :2

Para :2

No.of children: 2(1son-10yrs)(1daughter-12yrs)

IVD permanent sterilization is done in 2013

No abortions

BIRTH HISTORY:

FTND

No H/O birth asphyxia

GENERAL PHYSICAL EXAMINATION:

Patient is conscious,coherent and cooperative.

Mild pallor is present

No icterus, cyanosis and clubbing

No lymphadenopathy

Mild dehydration is present

VITALS:

Temp:100°C

PR: 88bpm

RR:12cpm

BP:80/50mmHg

SYSTEMIC EXAMINATION:

 CVS:

No thrills

S1&S2 heard

No cardiac murmurs

RESPIRATORY SYSTEM:

No dyspnoea

No wheezing

Position of trachea:central

Breath sounds-vesicular

ABDOMEN:

Shape of abdomen -scaphoid

No tenderness

No palpable mass

No hernial orifices

No free fluids and bruits

Liver-not palpable

Spleen-not palpable

Bowel sounds-heard

CNS:

No abnormality detected

INVESTIGATIONS:

HEMOGRAM

RETICULOCYTE COUNT:

PERIPHERAL SMEAR:

FEVER CHART:

HIV: Negative

HCV: Negative

HBsAg: Negative

LFT:

TB:1.21

DB:0.26

AST:26

ALT:10

ALP:95

TP:5.9

Alb:3.2

A/G ratio:1.22

RFT:

Urea:20mg/dl

Creatinine:0.7

Sodium:146

Potassium:4.2

Chlorine:10.5

ESR:85mm

Sugar,Albumin-Nil

Pus cells :3-4

E cells:2-3

MP: negative

S LDH:320.5

S Iron:82.6

CRP: negative

RA-factor: negative

WIDAL TEST:No agglutination

ECG:

USG Abdomen:

PROVISIONAL DIAGNOSIS:

Acute gastroenteritis

Ruptured sebaceous cyst on left thigh

Arthralgia secondary to viral?

TREATMENT:

Inj.Optineuron 1amp IV OD

Inj.Neomol 1gram IV SOS

Inj.Pantop 40mg IV OD

Inj Zofer 4mg IV TID

Inj.Ceftriaxone 1gm IV BD

Inj.Metronidazole 100ml IV TID

Tab.Sporlac -DS TID

Tab.Dolo 650mg PO TID

Tab.Redotil 100mg PO BD

Tab.Baclofen 12.5mg PO SOS

IVF-NS/RL 100ml/1hr

ORS sachets in 1ltr water 100ml

Tab.Chymoral forte PO TID

Tab.Hifenac P PO TID

Tab Vit-C PO OD