A 80 years old female with fever

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

CHIEF COMPLAINT:
Pt complaints of fever since 15 days and headache since 1 week 

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 weeks back then she developed fever of high grade , intermittent, associated with headache and was not relieved on medication.
H/O headache since 1 week 
No history of vomitings, loss of appetite, or SOB. 

PAST HISTORY:
Not a known case of hypertension, diabetes, epilepsy, asthma.

FAMILY HISTORY: 
No one in family have similar complaints. 

PERSONAL HISTORY: 
Diet- mixed
Appetite- normal 
Bowel and bladder movements- Regular
Allergies- No
Addictions- No

GENERAL EXAMINATION:
Pt is conscious, coherent and cooperative and well oriented to time,place and person.
No ,cyanosis clubbing,edema, malnutrition. 

VITALS-
TEMP- 101°c
BP- 110/70 mmHg 
Pulse rate-150bpm
RR- 16cpm


SYSTEMIC EXAMINATION:

CVS- S1 S2 heard
No thrills and murmurs 

RS- 
Trachea central
BAE+

Abdomen: Shape-scaphoid
No tenderness
No palpable mass
Liver and spleen not palpable 

CNS: conscious &alert
No focal 
Provisional diagnosis - pyrexia with bacterial infection. 

 
  widal test is positive. 

Treatment 
IV fluids
Inj. NEOMOL
Inj. MONOCEF
Inj. DOXY 
Tab. DOLO 650mg

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