43 YR FEMALE WITH CONSTANT ILL HEALTH THOUGHTS

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Here is a case that I have seen:

GM unit 3 admission on 17/2/21

Interns:

Dr Harsha

Dr Sreeja

Dr Archana

Dr Kalyan 

Dr Sahithi 

Dr Jeehariki

Dr Raveen PGY1

Dr Aashitha PGY2

Dr Aravind PGY3

Dr Vamshi PGY3

Dr Hareen SR

Dr Praveen Naik - Ass. prof

Dr. Rakesh Biswas - HOD 

43/F 

C/o : fever since 1 month on and off

         Burning micturition since 1 month 

         Generalised weakness + 

         Myalgia + 

HOPI:

Patient was apparently asymptomatic 1 month back.

He developed fever which was insidious in onset, intermittent type,  diurnal variation+

Fever was on and off, was on medication(?). 

Burning micturition + since 1 month 

generalised weakness + 

Myalgia + 

No H/O nausea/ vomiting/loose stools 

Past history: k/c/o asthma, on rotahaler (beclamethasone and levosalbutamol) 

Not a k/c/o T2DM, HTN, TB, Epilepsy 

Personal history: 

Diet-mixed

Appetite - decreased 

Sleep- normal 

Constipated , burning micturition + 

Drinks toddy occasionally 

No known drug / allergic history

No significant family history 

On examination: 

Patient was conscious/coherent /co-operative 

Thin built and moderately nourished 

No pallor/icterus/clubbing/cyanosis/generalised lymphadenopathy/pedal Edema 

BP: 110/70mmhg

PR: 98bpm

RR: 18cpm

SPO2: 98% at RA

GRBS-112mg/gl

Afebrile to touch

Systemic examination: 

CVS: s1,s2 heard

RS: BAE present,

P/A: soft, non - tender 

CNS: NAD

Investigations:

Diagnosis : 

?Viral Pyrexia

Treatment:

IVF 1unit NS and 1unit RL @75ml/he

INJ.PAN 40mg IV OD BBF

INJ.PCM 650mg IV SOS

TAB.DOLO 650mg PO SOS

SYP.CITRALKA 10ml in oneglass of water PO BD

20/02/21:

21/2/21:

22/02/21

Psychiatry referral was taken I/V/O constant I'll thoughts :

Diagnosed as Adjustment disorder due to personal issues.

Discussion: