35 YEAR OLD FEMALE WITH FEVER AND SEVERE HEADACHE

January 03, 2023

- January 03, 2023

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input..

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan .

A 35 year old female resident of nakrekal who is a house maker by occupation came with

Chief complaints-

1.Fever since 1 week

2.Headache since 1 week

History of presenting illness-

Patient was apparently asymptomatic 1 week back then she developed fever which is intermittent in onset(on and off),increasing at night time and decreasing in the morning,associated with chills and headache.

Fever is relieved by taking antipyretic.No history of Nausea,vomiting,rash or body pain.

History of unilateral headache since 1 week which is severe throbbing type in left fronto parietal occipital region radiating to the neck,it is aggravated on exposure to stress.Headache makes her wake up abruptly in the night leading to inadequate sleep.

Headache is associated with vomiting(just 1 episode),phonophobia and blurring of vision(history of change in spectacles),decreased regular physical activity,tingling sensation in hand and feet.It relieves on taking rest and medication.No history of aura,photophobia,depression,irritability,cravings,diarrhoea/constipation.

She has history of burning micturition since 5 days associated with decreased urine output,decreased frequency,left loin pain which is dragging type pain(since 2 days).No aggravating and relieving factors.No history of urgency,hematuria,nausea,vomiting.

Daily routine-

She gets up at around 5 AM in the morning,does her daily chores and helps her children get ready for school.She has her breakfast at 8.30 AM in the morning and then sleeps for sometime before preparing and eating lunch by 2 pm.She spends rest of her day by watching TV or doing daily chores.She used to work as a daily wage labourer before 6 years.

PAST HISTORY-

Similar episode one year back.

Not a known case of diabetes mellitus,hypertension,epilepsy,cardiovascular disease and tuberculosis.

History of hypothyroidism 10 years back.She was taking 50 mg thyroxine supplements until 2 years before when she had few episodes of lethargy and she had to consult a local doctor who investigated her thyroid profile and increased thyroxine dose to 75 mg thyroxine supplements.

History of renal stones in the left kidney 6 years back for which she took some conservative treatment.

Family history-

No significant family history.

Personal history-

Diet: mixed

Appetite: decreased

Sleep: Inadequate

Bowel and bladder: constipated

Addictions: none

No H/O of any drug allergy.

General examination-

Patient is conscious,coherent and cooperative.Well oriented to time,place and person,Moderately built and nourished.