GENERAL MEDICINE CASE 7
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28 yrs old female came to opd with chief complain of fever,headache,swelling on the neck and nausea
HISTORY OF PRESENT ILLNESS
patient was apparently asymtommatic 14 days back then she developed fever after taking her COVID VACCINE associated with vomitings for 2 days ( 4-5 episodes/day ) visited RMP took medications and fever subsided
C/o fever since 3 days with diffuse head ache type associted with nausea
Vomitings ( 2 episodes ) on 1st day of fever
No episodes of vomitings next two days ( only nausea feeling )
No cold , cough ,loose stools
C/o hair loss since 3 days
Weight loss since 3 years
No cold /heat intolerance
PAST HISTORY
5months back she c/o giddiness and she visited RMP where she was diagnosed of low BP
Married at the age of 15yrs
2009 - boy ( c section )
2011 - daughter
2013 - daughter ( had 2 blood transfusions)
2014 - 1 more transfusion due to less hb% and Tubectomy was done
Mentrual history :
age of Menarche 14 yrs
Cycles : Irregular menstrual cycles since 2years
Backache present
Stomachache present
Bleeding increased since 2 yrs
PHYSICAL EXAMINATION
No signs of icterus cynosis clubbing edema dehydration malnutrition
Pallor - present
Lymphadenopathy - present ( cervical )
Temp - 98.5 F
PR - 88 bpm
RR - 17 Cpm
Bp - 110/60mmhg
SpO2 - 98% at RA
Grbs - 141 mg/dl
SYSTEMIC EXAMINATION
Cvs : s1 s2 heard no murmurs
Rs : Nvbs +
P/a : soft , non tender
Cns : higher mental functions normal
INVESTIGATION
TREATMENT
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